University Hospitals Dorset NHS Foundation Trust

4. Miss T complains about the following aspects of care the Trust provided to her godfather, Mr G, in September 2023. She says it: •did not carry out a risk assessment to prevent him falling •did not lower the bed rails despite his previous attempts to leave the bed.

5. Miss T believes her godfather deteriorated and died due to poor care. She says his fall caused a bleed on his brain and could have been prevented. She says the Trust’s failure to demonstrate accountability added to her bereavement.

6. Miss T wants the Trust to acknowledge its failings and provide a sincere apology that these contributed to her godfather’s death. She also wants it to show it has made changes to prevent others having a similar experience.

7. Mr G was taken to hospital by ambulance on 28 August 2023 following a fall. The Trust carried out surgery on his hip a few days later. Mr G had a fall in hospital on 4 September and sadly died on 6 September.

Falls risk assessment

11. Section 1.2.1.2 of NICE CG161 states that all patients aged 65 and above being admitted to hospital should be automatically regarded as a high risk of falls. Mr G should have had a multifactorial risk assessment in line with NICE guidance. We consider it a failing this did not happen.

12. The Trust acknowledges it did not complete the falls assessment, which is electronic. It said this is not the level of documentation it aspires to, and it apologised for this. However, it is of the view ‘aspects within the assessment were appropriately actioned’. It told us NICE guidance CG161 is the foundation for guiding its assessments and planning care.

13. While clinical guidance was not followed in the form of a falls risk assessment, the Trust did complete a falls risk assessment plan. This did contain multifactorial interventions, such as having bed at appropriate height and ensuring one hourly wellbeing rounding.

14. The plan also had a section where the nursing team needed to assess whether Mr G required an enhanced level of supervision, and Mr G was deemed as not requiring it. Our adviser said this was probably because he was immobile following his fall and was on bed rest, being reluctant to even change position in bed with assistance. Therefore, it appears he was unlikely to try and get out of bed or mobilise independently.

15. The Trust’s falls risk plan resulted in Mr G being assessed as at high risk of falls. As a result, our adviser said the lack of a falls risk assessment had a minimal impact and would not have changed the care he received. We hope this reassures Miss T.

Bed rails

16. MHRA guidance says risk assessments should be carried out before the initial use of bed rails. Additionally, risk assessments should be reviewed and recorded after each significant change in the bed occupant’s condition or needs.

17. Guidance was not followed as we have seen no evidence the Trust carried out a bed rails risk assessment. The Trust has not provided any information to indicate this did happen. This should have been carried out to make a decision about using them or not. We consider the lack of a bed rails risk assessment is a failing.

18. The Trust’s complaint response said Mr G’s bed had been lowered as far as possible to minimise any damage if he fell out of bed. It also said bed rails should not have been raised.

19. It is now of the view it was appropriate to have them raised. It apologised for its previous letter. It explained its Falls Nurse Specialist has since confirmed staff must assess if bedrails are appropriate on an individual basis and on how the patient is presenting at the time.

20. The Trust told us other factors that staff would have taken into consideration ‘for example, was the fact that he was unable to mobilise when therapy reviewed him, he was post-surgery, was unwell with COVID-19 and could have been at risk of rolling out of bed (which is when it is appropriate to have the rails raised)’.

21. Miss T told us Mr G had made attempts to mobilise previously which the Trust was aware of. The Trust said there is no documentation that Mr G had been attempting to leave the bed. It said Mr G had his surgery on 1 September 2023 and had remained in bed following this, with assistance from the nursing staff with personal care and repositioning.

22. Our adviser said while not using the bed rails would have been justified due to Mr G’s confusion and agitation, the rationale now provided by the Trust for the bed rails being raised is understandable. It is not possible to say if Mr G would have fallen or not had they not been raised. He appears to have been reluctant to even change position and needed assistance to do that.

23. However, the decision to use bed rails should have been made following an individualised assessment based on Mr G’s circumstances. Our adviser said the impact of the lack of assessment and the use of bed rails is difficult to predict, but had he not had bed rails up, then he might not have fallen or suffered a lesser injury. We are proposing to make recommendations on this basis.

24. The Trust told us it remains very sorry that, despite every effort, Mr G sadly fell whilst in its care. It said it appreciated the impact this has had on Ms T and her family and it sincerely apologises for this.

1. We were very sorry to hear of Miss T’s concerns about the Trust’s care. We recognise this added to her bereavement following the death of her godfather, Mr G.

2. We have identified failings in relation to the Trust’s approach to assessing and managing Mr G’s risk of falls. This may have contributed to its decision to use bedrails. Miss T has been left with uncertainty about whether Mr G’s fall and injury were avoidable. we therefore partly uphold the complaint overall.

3. We recommend the Trust writes to us and Miss T to explain how it will improve its service. We also recommend the Trust pays her £425 in recognition of how the failings we have identified added to her bereavement.

25. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

26. While the lack of a falls assessment may have had no overall effect in this case, we have seen no evidence the Trust has taken action to ensure going forward, documentation will be completed as it should be.

27. There is also no evidence of a bed rail assessment to determine if the bed rails should or should not have been raised in this case. The Trust should therefore communicate this to staff and implement learning around the need for bed rails risk assessment.

28. Our Principles say that public organisations should look for continuous improvement, and should use the lessons learned from complaints to make sure they do not repeat maladministration or poor service. In line with this, we recommend the Trust writes to Miss T within six weeks of the date this report to: • acknowledge the failings we have identified and identify the reason(s) for the failing (where possible) • explain what action it will take (with timescales), or has taken, to prevent the failings happening again.

29. Our Principles say that public organisations should put things right and, if possible return the person affected to the position they would have been in the poor service had not occurred. If that is not possible, they should compensate them appropriately.

30. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. Following this review, we recommend that the Trust should pay Miss T £425 in recognition of the additional distress the failings we have identified added to her bereavement.