Falls plan 14. Mrs A complains the Trust failed to have a sufficient falls plan in place for her brother during his admission in December. She feels this caused him to fall on 9 December which caused his death, which she feels was avoidable.
15. The NICE guidance explains patients should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. It says the falls intervention should promptly address the patient's identified individual risk factors for falling in hospital and consider whether the risk factors can be treated, improved or managed during the patient's expected stay.
16. The bed rails guidance outlines the decision to use bed rails should be made with the consent of the bed user whenever possible. The reasons for the decision to issue bed rails should be effectively communicated and recorded.
17. The Trust created a falls assessment shortly after Mr O’s admission on 3 December within the ED which states he had a history of falls within the last 12 months, did not have cognitive impairment, took four or more medications and had issues with his mobility. The Trust also created a moving and handling risk assessment when he was transferred onto ward 6A, which states that Mr O could mobilise with the assistance of one staff member and could independently rise from lying down to a sitting position. He was given a call bell in the event he needed assistance from the nursing staff.
18. We consider this assessment is in line with the NICE guidance on ensuring there is a prompt assessment of the patient’s individual risk factors for falling as we can see Mr O was assessed shortly after his admission within the ED and again when he was transferred onto ward 6A.
19. Our nursing adviser explains as Mr O was at risk of falls, he should have had a multifactorial falls assessment completed and a falls care plan in place during his admission.
20. The records show the Trust completed a falls prevention care plan and multifactorial assessment on 4 December. The Trust’s falls prevention care plan explains the care plan should be implemented upon admission, then every week after the admission or if the patient suffers a fall before this point. This multifactorial assessment reviewed the risk factors Mr O had upon his admission to the ED, including his risk of falls, medication use, his overall mobility and his cognition. The records show the Trust completed a multifactorial review and risk assessment on Mr O during his admission which was in line with the NICE guidance on addressing a patient’s risk factors for falling in hospital, and our clinical advice supports this view.
21. The Trust also completed a bedrails assessment on 4 December which shows the risks and benefits of using bed rails were explained to Mr O. After this discussion Mr O decided he wanted to use bedrails when he was being nursed in bed. This is in line with the bed rails guidance on deciding about bed rails with the consent of the bed user, and our clinical advice supports this view.
22. We can see during Mr O’s admission, the Trust continued to carry out falls risk assessments on Mr O. On 7 December it deemed that he had become very confused and the Trust updated the records accordingly. During the ward round on the evening of 8 December, the ward manager planned to update the medical team and physiotherapists during the ward round the next morning, but sadly Mr O suffered a fall before this review could take place.
23. We can see the Trust promptly identified and recorded that Mr O was at further risk of falling after he developed confusion during the admission, and it updated this in the clinical records. This is in line with the NICE guidance on addressing the patient’s risk factors for falling and our clinical advice supports this view.
24. We can see the Trust did try to manage Mr O’s risk factors by planning a discussion with the medical team and physiotherapists to discuss his management following the development of his confusion, unfortunately this was not possible before he fell on 9 December. We consider falls this plan was in line with the NICE guidance on trying to treat, improve or manage a patient’s overall falls risk factors during their admission, and our clinical advice supports this view.
25. The Datix record (the record created after a patient safety event) from the fall shows Mr O had the bed rails and call bell in place at the time of the fall and he was aware of how to use it. The doctors felt Mr O tried to get out of his bed despite the bedrails being in place to use the bed pan, which Mrs A disagrees with. We will never know what caused Mr O to fall and understand how important this issue is for Mrs A. The records show he was found on the floor, which must have been very distressing for Mrs A to learn of, and it is clear from speaking to her how upset she remains due the fall her brother experienced during his admission. We are truly sorry to hear of how much she has been impacted by this.
26. Our nursing adviser explains there was a sufficient falls care plan in place prior to the fall and nurses were acting on Mr O’s increased confusion by informing the medical team, but sadly the fall occurred prior to medical staff arriving on the ward. Overall we are satisfied the Trust had a sufficient falls plan and support in place for Mr O during his admission, and our clinical advice supports this view.
Testing and pain relief after fall 27. Mrs A says the Trust failed to carry out appropriate tests after he fell on 9 December to establish the extent of his injuries and ensure he received appropriate treatment and pain relief prior to his death. She explains Mr O died in significant pain as he did not have sufficient support in place following the fall.
28. The GMC guidance explains clinicians must provide a good standard of practice and care. When diagnosing or treating patients they must: • adequately assess the patient’s conditions, taking account of their history, their views and values; where necessary examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this services the patient’s needs.
29. Following Mr O’s fall on 9 December at 7.30am, the nursing team made a Medical Emergency Team (MET) call, which is an urgent call to alert and request other staff for help when a patient’s vital signs have dropped. The MET record states Mr O had fallen and was sadly found in an unresponsive state. The MET carried out a review of Mr O’s airways, breathing, circulation, disability and exposure. It concluded he had hospital-acquired pneumonia, circulatory compromise and potential heart failure at this point. Doctors thought he had a poor prognosis and would not recover. We understand how difficult this must have been for Mrs A.
30. There was no significant concern that Mr O had injured either his head or any of his limbs following his fall and our physician adviser explains based on this there would be no indication for the Trust to carry out any imaging on Mr O. Our physician adviser told us there is no evidence to suggest the fall contributed to Mr O’s subsequent deterioration or death.
31. The Trust continued to review Mr O’s condition and felt his condition was continuing to deteriorate and he was reaching his end of life. The records show the Trust discussed Mr O’s condition with his family on 9 December at 10.57am to explain his overall prognosis and that the chances of survival were poor following his deterioration. The Trust subsequently treated Mr O with fluids, antibiotics and anticipatory medicine (medications provided at the end-of-life for symptomatic relief). Our physician adviser explains the Trust provided Mr O with appropriate treatment after his fall and subsequent deterioration.
32. We consider the Trust appropriately reviewed and treated Mr O following the fall which is in line with GMC guidance on adequately assessing a patient’s condition and providing appropriate treatment, and our clinical advice supports this view.
33. We have also considered Mrs A’s concerns that her brother died in pain after the fall. Mrs A explains she arrived at the hospital shortly after her brother’s fall and saw he was in pain and was very distressed. She says she had to ask on several occasions for pain relief and a sedative to ease his suffering and pain before he died. We have no reason to dispute this. We appreciate her strength of feeling and recognise this must be very upsetting. We understand how important this issue is for her.
34. The clinical records show after his fall on 9 December, the Trust reviewed Mr O at 10.57am and Mr O did not report to be in any pain. Doctors discussed Mr O’s condition with his family at 10.59am and explained they felt he was approaching his end of life. As part of this decision the Trust prescribed anticipatory medicines to Mr O, which included pain relief for any symptoms of pain. The Trust reviewed Mr O again at 1.02pm when it is reported he again had no complaints of pain. Mr O did not report to be in pain after this review until his sad death at 4.50pm. The clinical records show that Mr O’s condition and treatment plan was discussed regularly with his family, who agreed with the care and treatment provided.
35. We can see the Trust did discuss Mr O’s condition with his family and administered pain relief to Mr O following his fall. The evidence shows Mr O did not report to be in any further pain after this was given until he sadly died, which suggests his pain was well managed. Our physician adviser explains that based on the evidence available, the Trust did provide pain relief to Mr O through its use of anticipatory medicines towards the end of his life. They consider overall the Trust provided appropriate pain relief to Mr O after his fall.
36. Based on this we consider the Trust effectively managed Mr O’s symptoms of pain after he suffered his fall, which was in line with the GMC guidance on providing appropriate treatment where necessary.
37. Overall we are satisfied the Trust appropriately tested Mr O and managed his symptoms after his fall, in line with the GMC guidance on providing appropriate treatment. We hope that our findings give Mrs A some reassurance that we have not seen any evidence that the fall could have been avoided or that it caused Mr O’s sad death. Seeing a loved one’s condition towards the end of their life is understandably distressing and we are sorry to hear what Mrs A has been through.