14. To establish what should have happened during Mr O’s admission, our adviser referred us to NICE guidance, falls in older people, assessing risk and prevention. It refers to preventing falls in older people. It says, ‘older people who present for medical attention because of a fall or report recurrent falls in the past year or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment’. This guidance recommends ‘individualised interventions are considered when aiming to reduce the risk of patients falling’. This guidance applies because the Trust recorded that Mr O was known to have had previous falls in the previous 12 months.
15. The Trust carried out a capacity assessment for Mr O on the 15 May. It found he was not able to retain information and did not have capacity to make decisions.
16. In line with the above NICE guidance, the Trust carried out a falls risk assessment on 7 May. This showed he was at high risk of falls.
17. The Trust’s risk assessment document says if a patient is at high risk of falls, it must consider these actions:
• turnaround chart (to ensure two hourly checks) • nonslip socks • low profile bed • nursed in observation bed • one to one supervision • medication review • physiotherapy referral • mobility assessment • falls information leaflet to be given • bed rails assessment.
18. The medical notes show the Trust put measures in place for turnaround charts ensuring Mr O received regular checks, nonslip socks, and a physiotherapy referral. The Trust moved Mr O to an enhanced supervision bay and it arranged a bed rails assessment. The Trust also carried out further risk assessments on 10, 17, 24 and 25 May. The Trust recorded Mr O remained at high risk of falls and was known to have previous falls in the last 12 months.
19. On 12 May, the Trust recorded Mr O’s mobility was unstable and he had a history of previous falls. On 19 May, the Trust recorded Mr O kept trying to stand either from his bed and chair. He lacked insight of the risk. He needed someone to sit next to him to provide one to one observation because he was going to fall. He was unsteady on his feet and his legs were not very strong.
20. Unfortunately, Mr O had a fall on 25 May. The Trust completed a post falls clinical assessment afterwards. We have reviewed this, alongside the Trust’s investigation document. It recorded Mr O was behind the curtain using a commode. It says a member of staff was on the other side of the curtain to give him privacy. The member of staff heard a loud bang. The fall was unwitnessed. The staff member found Mr O on the floor, face down, bleeding from his forehead. Mr O said he was trying to walk around the commode and fell. He sustained a head injury, laceration to his forehead and an elbow skin tear. After the accident, the Trust updated his falls assessment to say it should not leave Mr O alone behind the curtain.
21. We have seen a copy of the Trust’s patient falls policy. It refers to the use of a baywatch which is an enhanced supervision bay. It says ‘this bay must always have a member of staff providing visual observation to the patients in the bay at all times’. We can see the Trust put some measures in place to reduce Mr O’s risk of falling. It is our view his level of supervision was inadequate. Mr O remained in an enhanced supervision bay but it does not appear the Trust always provided visual observation.
22. We appreciate the nurse said they were on the other side of the curtain providing privacy to Mr O. Our adviser helped us understand, although the nurse was close by, this is not appropriate supervision. We have decided the Trust should not have left him unsupervised because it was not safe to do so. This amounts to a failing.
23. We understand that preserving Mr O’s dignity was important. His key needs were for the Trust to keep him safe from falling. The nurse could have considered other ways to keep an eye on Mr O whilst reserving his dignity. The nurse could have ensured they were in view and reach of him, to ensure his safety. Mr O was in an enhanced supervision bay, he had lack of insight into his risk of falling and did not have the capacity to retain information. The nurse told Mr O to let her know when he had finished on the commode. Our adviser helped us understand that he did not have the ability to remember the information and maintain his safety. The Trust noted this in its own capacity assessment on 15 May. It also noted his risk of falling and need for one-to-one observation on 19 May.
24. The Trust responded to Mr R’s complaint in a letter dated 5 July. It apologised for the upset caused by the events. It said his father’s fall was correctly documented, it followed protocol, and the Trust’s ward team regularly assessed his father’s situation to see what additional support it could put in place.
25. The Trust carried out a risk assessment in line with NICE guidance. However, it did not follow through with its measures to keep Mr O safe from falling when he was behind the curtain using the commode. This was not in line with its own policy and NICE guidance.
Impact
26. Mr O unfortunately suffered injuries as a result of the fall. Mr R explained this caused his father pain and distress, and added to his confusion. Mr R was also upset by his father’s injuries and this caused distress. He was worried about his father’s future care and safety.
27. The Trust arranged a CT scan of Mr O’s head, he had stitches and needed a pressure dressing because the wound kept bleeding. The Trust arranged maxillofacial (a specialist in injuries to the face) to see Mr O and gave him pain relief. It recorded he was agitated and the wound was ‘down to the muscle’. The Trust contacted Mr R about his father’s accident. Mr R was not happy because they had previously discussed five previous falls and the Trust needed to continually supervise his father. The doctor apologised for this.
28. We can understand that this must have been a worrying time for Mr R, especially due to the nature of the injuries his father sustained. We do not underestimate Mr R’s upset and worry for his father’s injuries, safety and future care. We cannot say that better supervision measures would have prevented the fall, because we do not know how the fall happened. Had the nurse ensured Ms O was in their eyeline and reach, this could have provided the opportunity to prevent the fall or made the fall more gentle. The missed opportunity led to Mr R’s distress whilst his father remained in hospital.
29. When considering the injustice, we have considered what actions the Trust has taken to put this right. We have seen no evidence the Trust has taken action because it did not find anything went wrong during its own investigation of the complaint. It apologised for the upset caused by the events. It said Mr O’s fall was correctly documented, it followed protocol, and the Trust’s ward team regularly assessed his father’s situation to see what additional support it could put in place.
30. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.
31. We cannot say, even on the balance of probabilities, whether the nurse could have prevented Mr O’s fall had he been in their eyeline. It is entirely possible he may still have fallen. The Trust’s actions meant he was denied the possibility of the nurse being able to prevent it or helping him fall more safely. We know this leaves Mr R with some uncertainty on this aspect of care which is an injustice to him. We have made recommendations to the Trust to address this.