Fall
14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. We recognise the devastating impact of Mr Y’s fall. We cannot link the events complained about with the negative impact Mr Y has claimed.
15. Mr Y complains because of the Trust’s negligence he fell from the trolley.
16. The Trust said a full review of Mr Y’s case was completed, and it was presented to the Trust’s Harm Free Care panel to ensure the review covered all aspects of his care and treatment.
17. The report details the incident and notes the injury was not diagnosed until five weeks and three days after it occurred. It notes Mr Y was informed of the fracture, and management was discussed.
18. As a result of the complaint, the Trust notes lessons were learnt such as the escalation of any incident/injury for review by the doctor. An action plan was formulated as part of the review. The action was to discuss the incident with staff and ensure any concerns/injuries are escalated to medics for review. It also included to ensure all staff were aware to report any near miss incidents.
19. Paragraph 4 of the Nursing and Midwifery Council’s (NMC) ‘the code’ guidance says nurses must ‘act in the best interests of people at all times’
20. The notes state the nurse looking after Mr Y on the day reported when he came back from his MRI scan, the porter and the nurse assisted him off the trolley, and back to bed. They stood at each side of him and assisted him. The notes also state as he stood from the trolley, he appeared to stumble, and his legs gave way.
21. We can see the investigation report states Mr Y went into a ‘half-sitting’ position and that he ‘did not fall to the floor’. While there is room for interpretation of what defines a fall, our adviser says it could reasonably say this did not constitute a significant fall.
22. There is no indication from the notes to suggest the nurse or the porter caused the fall. From the information in the investigation report, we consider Mr Y was supported by the nurse and porter so that he did not fall to the floor.
23. We are very sorry to hear Mr Y’s concerns about this and appreciate it would have been very distressing. From the evidence we have reviewed, we consider the nursing team acted in Mr Y’s best interests, in line with NMC guidance ‘the code’. Given this, we cannot see any indications of failings.
24. We then looked at whether the Trust carried out appropriate checks and examinations after Mr Y’s fall and if there was a lasting impact of the fall.
25. From the evidence, it appears Mr Y had some pain immediately at the time of the injury as he ‘did shout in pain and became very angry’ but not subsequently. The notes state Mr Y ‘did not complain of any pain to his left foot following this incident for the rest of the time he was on AMU [acute medical unit]’.
26. The records show Mr Y’s bones appeared generally osteopenia (reduced bone density), and our adviser says this probably occurred with minimal trauma.
27. The NICE quality standard 86 on ‘Falls’ says ‘when a person falls, it is important that they have a prompt medical examination to see if they are injured and to assess for any change in their underlying medical condition. This is critical to their chances of making a full recovery. Timescales for medical examination should be included in a post-fall protocol that is followed for all people who fall in hospital.’
28. In terms of the monitoring after Mr Y’s fall, our adviser says he should have had a medical review. The records show in the days after the fall Mr Y was seen on the medical ward round regularly with no note being made of any issues with his left foot. Our adviser says if this was causing Mr Y an issue, this would have been raised and documented in the notes.
29. The Trust has explained it shared learning at the nursing safety briefing with an action plan which states two actions. The first states ‘discuss incident with staff and ensure any concerns/injuries are escalated to medics for review’.
30. Our adviser says this does not go far enough as it does not identify all patients who have had fall should have a medical review. While in this case no injury was apparent, our adviser explains the absence of injuries recognised by nursing staff should not negate the need for a medical review.
31. As such, we approached the Trust on 6 January 2026 to state whether they would incorporate the above advice into a future action plan in line with NICE QS86.
32. The Trust confirmed on 27 January, the patient safety manager and the matron at the Trust considered our request. It gave us reassurance about the process relating to falls. It said an appropriate medical review is in place and was in place at the time of Mr Y’s fall. It also said the action following a review of Mr Y’s care identified learning and resulted in discussions with staff during safety huddles which reiterated the importance of escalation for a medical review where an incident or injury has occurred.
33. This is in line with NHS complaint standards, which state: ‘Organisations support and encourage staff to be open and honest when things have gone wrong or where improvements can be made. Staff recognise the need to be accountable for their actions and to identify what learning can be taken from a complaint. The Trust are clear about how the learning will be used to improve services and support staff’.
34. The second action recommended by the Trust states ‘ensure that all staff are aware to report any near miss incidents’.
35. Our adviser says this is reasonable. It is also in line with NHS England’s ‘policy guidance on recording patient safety events and levels of harm’ which states ‘incident recording is mandatory in certain circumstances and very much encouraged in all others.
36. We realise how distressing it was for Mr Y when he fell. We consider the Trust should have medically reviewed him. Given there does not appear to be any significant impact, we are satisfied the Trust has acted in line with NHS Complaint Standards and taken accountability and appropriate steps to learn from the experience.
37. We do not think it is possible to attribute the deterioration reported in Mr Y’s health, including the need for carers, solely to the impact of the fall in December. Mr Y’s health was sadly deteriorating prior to his fall under the care of the Trust. As he has told us he had a boot on his right foot at the time following a major operation, and he also had a stroke.
38. We are in no way saying the injury sustained from the fall did not impact on Mr Y’s health or make his care more difficult. We consider the Trust has taken the appropriate action in line with NHS Complaint Standards to take learn from the experience. We also know Mr Y was unwell prior to being admitted to the Trust. We cannot attribute the need for carers solely on the injury sustained during his fall in August 2023.
Follow-up and investigation
39. Mr Y complains following the X-Ray of his left foot, no follow up appointments were organised. He says as a result, his foot was discoloured. He was not happy about this.
40. The Trust says it spoke to the therapy team, and this was due to the length of time from injury to X-Ray. It says the X-Ray of Mr Y’s left foot was completed over five weeks after the date of his injury.
41. It refers to the records by stating he was fully mobilising on his left foot during his interactions with therapy staff as part of his rehabilitation and there was no further treatment of therapy input indicated at that time, in relation to his fracture.
42. The Trust explains it is recorded as having been explained to Mr Y by the therapist, and it was also reported a discussion took place in relation to normal fracture healing times.
43. The British Orthopaedic Foot and Ankle Society (BOFAS) in ‘Metatarsal fractures’ explains for undisplaced fractures (where the broken pieces of bone are still aligned well), management without an operation is indicated. BOFAS suggests the treatment for these fractures include:
• ‘Splintage for 4-6 weeks • stiff-soled shoe, plaster shoe, walker boot • below-knee lightweight cast • Weight bearing as comfort allows (‘unrestricted’) • Most fractures heal within 6 weeks with return to normal activities soon after’.
44. The physiotherapy notes dated 18 September 2023 note Mr Y was able to fully weight bearing, for example, standing and walking on his feet, and he had been able to weight bear after the initial injury when transferring from the trolley.
45. Our adviser explains as Mr Y was more than four weeks from the injury and he was able to fully weight bear, no further active management was required. This is consistent with the BOFAS treatment guidance.
46. Our adviser says this is a good outcome from this injury and as he had made good progress there would have been no indication for a fracture clinic appointment. Our adviser also explains there would be nothing more to do with this minor fracture as Mr Y had recovered well.
47. The evidence shows while the assessment was completed by the physiotherapist, there was a discussion with the Advanced Clinical Practitioner (ACP) who agreed with this management. Our adviser explains at this point there was nothing realistically which would be added by further review from the ACP or a doctor, and this was reasonable. As such, we do not find anything went wrong here.
48. We were sorry to hear about Mr Y’s experiences in hospital and the deterioration in health he has experienced. Our decision does not take away the importance of Mr Y’s complaint and our awareness of the concern and distress it caused him.