Breached own guidelines 18. Mr Y has stated that the Trust was in breach of its own guidelines because staff left Mrs Y on her own and this resulted in her falling.
19. The Trust placed Mrs Y on level three observations due to her increased risk of falls. Level three observations require ‘line of sight’ observation and state that staff should not leave the bay unattended. In the early hours of 4 August, the staff member responsible for observing the bay briefly left to retrieve a commode for Mrs Y. During this time, records suggest Mrs Y attempted to mobilise, became incontinent, and slipped on the floor.
20. The Trust has noted that the fall was unwitnessed, and this means there were no staff present at the time.
21. The Trust’s falls policy lists reasons why patients require each level of observation. Mrs Y met the requirement for level three observations because she was confused and unsteady. This increased her risk of falls. The falls policy also recognises that clinical judgment is essential and allows for brief absences for staff to meet patient needs, such as retrieving equipment.
22. While the Trust’s falls policy advises staff not to leave the bay unattended, it also allows for brief absences based on clinical judgment. Our adviser explained the decision to retrieve a commode for Mrs Y was reasonable and consistent with expected practice. Only level four observations, which are continuous one to one observation, guarantee constant supervision.
23. Considering the guidance, we cannot say the nurse leaving Mrs Y’s Bay briefly indicates a failing. We recognise Mrs Y had a fall while the nurse was absent and recognise how distressing this has been.
Contradictory accounts and who raised the alarm
24. Mr Y told us the Trust’s investigation contains conflicting accounts of what staff were doing at the time of Mrs Y’s fall. He also said another patient told him they witnessed the fall and raised the alarm, which differs from the Trust’s account that a nurse did so.
25. PSIRF guidance says investigations should aim to provide a clear and consistent account of events. It also recognises staff recollections may vary, especially in busy clinical settings, and encourages organisations to acknowledge and explore discrepancies.
26. It appears the Trust’s investigation report did not adequately reconcile these differing accounts. There were inconsistencies between the nursing notes, Mrs Y’s intentional rounding records (where health profession record they have performed regular, proactive checks on patients, typically every one to two hour), and incident reports about the timing and circumstances of her fall.
27. For example, one account records Mrs Y’s fall at 12.15am on 4 August, another at 2.30am. Some reports say a nurse raised the alarm, while others say another patient did. There are also differences about whether Mrs Y was trying to reach the toilet or slipped in the bay. The Trust did not fully address these variations in its report. This was not in line with PSIRF guidance, which says organisations should explore discrepancies.
28. We considered what difference this made to the investigation findings. The variations in the accounts do not alter the evidence about the clinical care Mrs Y received afterwards. Staff checked her, completed observations, and arranged medical review.
29. While these discrepancies did not affect the clinical findings, we acknowledge it clearly contributed to the family’s frustration and reduced confidence in the process. We understand how upsetting this has been for Mr Y.
30. Given the passage of time and the limitations of the available records, it would not be proportionate to pursue further investigation now to clarify these events. This would be very unlikely to resolve the discrepancies or provide a definitive account, and it would not change the evidence about the care provided.
31. The Trust did not acknowledge the distress these inconsistencies caused. Recognising this impact could have helped reassure Mr Y and his family.
32. The NHS Complaint Standards require complaint handling to be thorough, fair, open and honest. The Trust’s failure to reconcile or acknowledge the discrepancies fell short of these standards. This is indicative of a failing.
33. The unresolved inconsistencies have added to Mr Y and his family’s grief by leaving them without a clear account of events. Under our Severity of Injustice scale, we consider this falls at Level 3. This is because there appears to be a link between what went wrong, and Mr Y’s bereavement.
34. The NHS Complaint Standards also set out the importance of putting things right for people and learning from mistakes.
35. We therefore approached the Trust to ask whether it was willing to take some further steps to provide a remedy for Mr Y. It has now agreed to: • provide Mr Y with a written apology acknowledging the impact of the inconsistencies and the distress caused • pay him £600 in recognition of the additional distress and uncertainty • ensure future Patient Safety Incident Investigation reports explicitly acknowledge and explore discrepancies in staff accounts, in line with PSIRF guidance.
36. We consider these actions to be a fair and proportionate resolution. We understand we have not been able to answer all of Mr Y’s questions. We hope the agreed actions provide reassurance that his concerns have been taken seriously and that lessons will be learned.
Staffing levels 37. Mr Y is concerned that staffing levels contributed to Mrs Y’s fall. He questions how the Trust can say they did not, given that no staff were present when she fell.
38. NICE guidance says safe staffing is essential to safe care. It explains that staffing decisions must consider patient acuity (how ill patients are), dependency (how much support patients need), and turnover (how often patients are admitted or discharged).
39. Except in intensive and critical care areas, there is no fixed nurse-to-patient ratio that applies across all wards. Each ward must determine its staffing needs based on its patients and environment.
40. The Trust’s post-falls report indicates that staffing levels did not contribute to the fall. It notes that there were no unfamiliar staff on duty, no additional patients boarding on the ward, and no evidence that patient acuity (severity of an illness or medical condition) affected the delivery of enhanced observation.
41. Our adviser confirmed the ward was staffed in line with expected levels and the Trust appropriately placed Mrs Y on level three observations. They noted that the staff member faced a difficult decision: either leave the bay briefly to get a commode or stay and risk Mrs Y becoming incontinent or distressed.
42. These decisions are common in practice and require quick judgment. Had the commode been brought into the bay, the nurse would have been behind the curtain with Mrs Y, and other patients would have been out of sight.
43. Taking Mrs Y to the toilet would have required leaving the bay entirely, which posed similar risks. Using a commode was a practical and safer alternative.
44. While Mr Y has questioned the role of staffing, taking account of the evidence, our advice and relevant guidance, we consider the Trust has provided a reasonable response in relation to this.
Whether the fall caused harm 45. Mr Y questions how the Trust could conclude the fall did not cause harm to his mother, given that Mrs Y died shortly afterwards.
46. We understand how difficult this is to hear. Any fall in hospital is serious, and we recognise the distress caused by the suggestion it did not result in harm. PSIRF guidance says investigations should be open and honest, acknowledge the perspectives of those affected, and provide a reflective account of events.
47. The clinical records show that immediately after the fall Mrs Y was alert, moving all her limbs, and said she had not hit her head. The Trust noted no injuries on examination.
48. A few hours later, Mrs Y’s condition deteriorated, and a CT scan showed a bleed. The medical team concluded this was secondary to her existing brain tumours, not the fall. The records describe the bleed as ‘most likely tumour bleed’.
49. We noted the Trust completed a falls risk assessment, implemented level three observations, and used interventions such as non-slip socks.
50. The post‑falls review recorded that staffing levels and patient acuity did not contribute to the fall.
51. Taking all these factors into consideration, in these circumstances we cannot say the Trust’s conclusions were unreasonable. This is consistent with PSIRF standards, which require organisations to reach proportionate conclusions based on the available evidence, and to distinguish between clinical harm and wider impact.
52. We recognise describing the fall as causing ‘no harm’ does not reflect the emotional impact on Mr Y and his family. The fall was a distressing event, and clearer communication from the Trust about the difference between clinical harm and emotional harm would have been appropriate.