8 August – Inpatient fall
26. Mr A is concerned his mother had an inpatient fall whilst using the hospital bathroom. He says she was unsupervised in the cubicle and fell, hitting her head on the sink whilst trying to get up from the toilet. Mr A feels frustrated the Trust left her unsupervised and believes this accident could have been prevented.
27. We recognise this must have been highly distressing for Mr A and his family and do not wish to underestimate how difficult this must have been for them.
28. The Trust said in its final response that Mrs A was accompanied to the bathroom by a student nurse. The nurse reminded Mrs A to use the call bell when she was finished so she could be assisted.
29. As a result of the fall, Mrs A sustained a knock to her forehead, broken skin, and bleeding. The Trust completed neurological observations, including a CT scan (medical imaging technique) which showed no significant concerns. The doctor recommended that Mrs A stay in hospital overnight for further observations.
30. The Trust explained, when supporting patients who have capacity to make decisions for themselves (like Mrs A), staff aim to maintain dignity and privacy when helping in the bathroom. This approach includes respecting patients’ wishes.
31. The Trust apologised to Mr A during a phone call after the fall and assured him staff would stay with patients where necessary to avoid similar incidents in future.
32. NMC guidance says,
• ‘nurses must deliver the fundamentals of care effectively.
• care, treatment, or assistance should be delivered without unnecessary delay.
• nurses must work in partnership with patients to ensure care is delivered effectively.
• nurses must focus on preventing ill health, promoting wellbeing, and meeting the distinct and changing health needs of people throughout their lives.’
33. The NHS Constitution states, ‘maintain the highest standards of care and service, treating every individual with compassion, dignity and respect, taking responsibility not only for the care you personally provide, but also for your wider contribution to the aims of your team and the NHS as a whole’.
34. NICE QS15 guidance emphasises that patient’s right to privacy and dignity are integral parts of care and should not be compromised.
35. We reviewed Mrs A’s medical records and found on 20 July the Trust completed a moving and handling assessment, with regular reviews until 8 August. The assessments indicated Mrs A was not independently mobile and needed one person to assist her with moving from sitting to standing, walking under supervision and vertical sit to sit transfers.
36. The notes also show the falls assessment (evaluates an individual’s risk factors for falling, or those with mobility issues) indicated she was at high risk of falls due to unsteadiness on her feet and a history of falls.
37. The BJN article states falls are very common in older frail people. Even if a patient has increased levels of supervision, not all falls can be prevented.
38. Our nurse adviser explains after a patient has a fall, they require reassessment to review any injuries (ABCDE assessment refer to airway, breathing, circulation, disability, and exposure). If a patient sustained a head injury, a CT scan should be arranged, and any possible fractures would require an X-ray.
39. Once a patient has been stabilised, staff should continue to monitor them and record observations.
40. The records show evidence of a post falls care chart dated 8 August. This demonstrates that the appropriate steps, including continued monitoring, were taken after Mrs A’s fall.
41. We have found, it is likely Mrs A attempted to get up from the toilet on her own. We have found this led to her fall, because the records show she was unsteady on her feet and at high risk of falling.
42. Our nurse adviser helped us understand the assistance provided by the nurse was appropriate up to the point of used the toilet in the cubicle. At the time, Mrs A had the capacity to make her own decision and there is no evidence to suggest she did not understand the nurse’s instructions.
43. The medical notes show the nurse informed Mrs A to use the call bell when she had finished so she could assist her in getting up from the toilet. This was a clear action by the Trust to minimise the risk of harm while maintaining Mrs A’s privacy and dignity. We consider this approach is in line with the NHS Constitution and NICE guidance mentioned above.
44. Our nurse adviser told us the Trust did not follow the falls assessment which indicated staff should not have left Mrs A unattended. We have carefully balanced this evidence with the other available evidence, as well as our expectations of the Trust’s actions based on the NHS Constitution and NICE guidance.
45. We recognise that increased supervision, such as the nurse staying in the cubicle with Mrs A, could become intrusive for some patients. It is reasonable to suggest Mrs A may have strongly preferred not to have a stranger present while using the toilet.
46. Based on the above advice and guidance, closer supervision (the nurse directly in the cubicle with Mrs A) could have helped reduce the risk of a fall. However, it would have compromised Mrs A’s dignity and privacy. We cannot say with certainty that closer supervision would have prevented the fall entirely.
47. We have reviewed the BJN article, which explains that falls can still happen even under enhanced one-to-one supervision. The study shows during 2022, 314 falls were reported within a division (part of a large hospital Trust in the UK). 61 falls occurred whilst under enhanced supervision, and 23 took place when the patient was due to be under one-to-one supervision. This shows increased supervision or one-to-one supervision does not completely remove the risk of falls.
48. Based on the evidence, including guidance from NMC and the NHS Constitution, we have found that enhanced supervision would have conflicted with important guidelines, particularly those relating to maintaining dignity and privacy. We have found no failing here.
49. While closer supervision might lower the risk of falls in general, it cannot completely eliminate the possibility of them happening. Furthermore, we cannot say, even on the balance of probabilities, that closer supervision would have prevented this incident.
Physiotherapy
50. Mr A is concerned about the physiotherapy assessments staff completed during his mother’s admission. He believes his mother was not mobile and unable to care for herself. He disagrees with the results of the assessments and feels they are incorrect.
51. The Trust explained in its final response that Mrs A was mobilising with a walking stick and using the stairs with supervision. Following the physiotherapy assessments, the Trust arranged for a care package to support her at home. This included supervision with the stairs, personal care, meal preparation, and medication. The Trust has not commented on the quality of the assessments in its response.
52. HCPC guidance says physiotherapists must:
• ‘be able to practice as an autonomous professional, exercising their own professional judgement • be able to make and receive appropriate referrals’.
53. CSP guidance says physiotherapists should gather relevant information about the service user and their presenting needs. This information should then be used to analyse and assess the situation in order to formulate a treatment plan.
54. After careful consideration of the medical records and with the help of our physiotherapy adviser, we find that the physiotherapy assessments were appropriate for Mrs A’s care needs.
55. This is because the frailty assessment (systematic evaluation used to identify and measure the level of frailty in older adults to tailor appropriate care and support) included a thorough evaluation of Mrs A’s background.
56. The physiotherapist considered her health and mobility before her admission, during her stay, and her ability to transfer (bed to toilet) and walk on the ward.
57. The notes show that, at the time of the assessments, Mrs A did not require additional equipment. However, it was recorded that the activities the physiotherapist asked her to perform were ‘effortful.’
58. The records also show evidence that this was planned for, as a Therapy Assistant Practitioner (TAP) provided a toilet frame and commode during her admission on 5 August. The Trust completed a referral to the Community Occupational Therapist (OT) to assess her home for adaptations, including a handrail or stair lift.
59. In addition, the notes show evidence the Trust gathered a collateral history from Mrs A. This was appropriate for ongoing assessments and is in line with the CSP guidance. This is recognised as appropriate practice and helped to develop a care package that suited Mrs A’s needs.
60. The records show the care package included an OT referral and a falls clinic referral. This clinic provides interventions around physiotherapy and falls and exercises. These actions align with the guidance referenced above.
61. On 1 August there was further input from an OT (‘discussion with patient who is still happy with the plan when medically fit… she does not want a Zimmer frame and feels that a once a day package of care will suffice’). This is evidence of Mrs A being involved in the decisions about her plan of care.
62. On 5 August there was an assessment by a TAP, they work alongside physiotherapists and OTs to support assessments. Our physiotherapy adviser explains the assessment was comprehensive and detailed mobility and transferring.
63. CSP guidance for communicating the results of the assessments says physiotherapists must:
• ‘exercise and explain sound professional judgment in their physiotherapy activity and decisions are informed by evolving evidence base • use available information and evidence to assess risk and make decisions.’
64. The evidence shows the physiotherapists considered the specific environment Mrs A was in when completing her stair assessments. These assessments were conducted based on the hospital setting, not her home. The notes reflect that the Trust recognised Mrs A would need direct supervision on the stairs at home. They also arranged toileting support to be available downstairs at her home.
65. Our physiotherapy adviser explains some Trusts operate with a ‘home first’ approach, especially since the COVID-19 pandemic. This approach ensures patients can return home as soon as it is safe to do so, with appropriate support in place.
66. We have seen evidence the Trust updated the care package throughout her admission and were responsive to her needs. There is also clear documentation showing the conversations they had with the family, and that the Trust were aware of Mr A’s concerns.
67. Mr A has raised concerns about the quality of the physiotherapy assessments and expressed disagreement with the physiotherapist’s findings. Our physiotherapy adviser confirms there is no specific guidance addressing how to resolve a patient or family member’s disagreement with assessment outcomes. However, if someone is unhappy with an assessment, it would be reasonable for the physiotherapist to offer a second opinion.
68. Our physiotherapy adviser explains ‘independent with walking aid’ means they do not need another person to assist them with that. Mrs A had a walking frame and that is an option and down to patient choice.
69. In addition, it is reasonable to expect Mrs A’s independence and mobility to change in hospital. This is because, any acute hospital environment that is unfamiliar to a person may make them ask for a person to assist them or not. It is important to remember she was being assessed for the environment she was in, not her home.
70. After careful consideration of the physiotherapy assessments, advice and guidance and from the evidence, we find the physiotherapy assessments were appropriate and robust.
71. This is because, the assessments were used to implement and agree a package of care to support Mrs A in her own home. We can see evidence in the records which shows the Trust adapted this care package during the admission to suit Mrs A’s change in needs. It is likely that without these robust assessments Mrs A’s needs would not have been met through the care package.
Discharge on 9 August
72. Mr A does not believe his mother was fit for discharge. He has said that, during her hospital admission, she was losing weight, had cognitive impairment, and was very frail. Her leg injury was still healing. He has also raised concerns that the Trust referred Mrs A for home assessments to make adaptations, such as handrails for her stairs, but these did not take place before her discharge.
73. Mr A’s main concern is that the Trust should not have discharged Mrs A at all. He believes this contributed to her fall at home on 13 August, four days after she left hospital. She was admitted again with a broken neck of femur and sadly died on 23 September.
74. The Trust has said that at the point of discharge his mother was mobilising with a walking stick and negotiating the stairs with supervision. It said it set up a care package to ensure she had regular calls throughout the day, would be supervised on the stairs and have support with personal care, meal preparation and taking her medication.
75. NICE guidance on discharge planning says,
• ‘point 1.5.13 ‘from admission, or earlier if possible, the hospital and communitybased multidisciplinary teams should work together address factors that could prevent a safe, timely transfer of care from hospital • the discharge coordinator should work with the multidisciplinary teams and the person receiving care to develop and agree a discharge plan • the discharge coordinator should account for the patient’s social and emotional wellbeing, as well as the practicalities of daily living • the discharge coordinator should discuss the need for any specialist equipment or adaptations ensuring that any essential specialist equipment and support is in place at the point of discharge.’
76. After careful consideration of the medical records, our physician adviser explains Mrs A was medically fit for discharge. They explained this decision is made jointly by the doctors and nurses on the ward, based on the clinical symptoms at the time.
77. We have not referred to guidance for this part of the complaint because our adviser has not told us there is specific guidance that is relevant. Rather, we have used the physician adviser’s professional opinion.
78. During Mrs A’s admission (for her fall at home on 20 July) the Trust performed appropriate investigations including an X-ray to exclude a fracture. Attention to the cause of falls was given including lying and standing blood pressure measurements. Mrs A’s blood pressure and potassium was low (due to indapamide use – medication for high blood pressure) which was addressed with her blood tests improving.
79. On 1 August, Mrs A was reviewed by the OT and said she was happy with the discharge plan as the carers were due to visit her once a day. The Trust informed her the community OT would conduct the home assessments. Our final report considers everything that happened up to discharge (and whether it was appropriate) that concerned the Trust and its actions.
80. Mrs A’s clinical observations were within acceptable limits prior to being discharged and the notes show she was medically fit for discharge as early as 4 August.
81. The notes show a stairs assessment was completed on 5 August with a note that she was not to use them independently.
82. On 8 August she had an inpatient fall when she stood up after using the toilet and fell and injured her head. Our physician adviser explains post-fall investigations were reasonable, including a CT scan and medically she was still fit for discharge. It is noted Mr A was concerned about future falls, but that ‘she will not go into a home and wants to live independently.’ These notes also say she needed supervision with going to the toilet and minimal support (but support nevertheless).
83. The Trust completed the Pathway 1 discharge care plan. This focuses on safely transitioning individuals from hospital to home after they are no longer acutely unwell before discharge. The discharge plan details Mrs A previously using the stairs multiple times per day (as her toilet was upstairs).
84. It was noted that since her admission she needed supervision on the stairs because she could not use them safely on her own. The notes show the Trust explained this to her and she agreed to wait for carers to assist her on the stairs at home.
85. The discharge plan also includes provision for carers to empty her commode, so she was provided with a commode downstairs to use while on her own. This would be a reasonable and practical arrangement, as she could not be expected to wait for carers each time she needed the toilet. The discharge plan details a twice-daily care package to meet her needs.
86. The discharge plan also shows the Trust completed a referral for the falls clinic. This is a specialised program focused on falls prevention and support for individuals at risk of falling. It is also noted, the Trust ‘had suggested referral to community OT for second handrail on stairs’ and ‘referral to community OT please.’ There is evidence to show this was completed and our physician adviser confirms these referrals were appropriate.
87. Our physician adviser explains after 8 August when Mrs A had an inpatient fall with a head injury, the Trust noted she required supervision and assistance with toileting. There would be a reasonable expectation that Mrs A would fall again while using a commode.
88. Whilst Mrs A’s discharge came with some elevated risks, we consider the decision to discharge her was still appropriate. These risks were known and the Trust discussed them with the family throughout her admission. It would not have been new information for the family to be told about the risks involved in Mrs A returning home.
89. We also considered whether the adaptations to the home should have been a factor in deciding whether Mrs A could be safely discharged. Our physician adviser explains there were reasonable plans in place to equip the home, for example with the second stair rail.
90. Adaptations often take time, and it was appropriate to allow the referral process to continue in due course, managed by the community OT. There was an agreement that Mrs A would not use the stairs unsupervised, and this reduced the immediate risk.
91. We also contacted the Trust and asked if it could confirm if the Local Authority received the referral prior to Mrs A’s discharge date. The Trust confirmed it had confirmation (via email and verbally) from the Local Authority prior to Mrs A’s discharge to confirm the package of care was in place.
92. Our physician adviser explains if Mrs A was not discharged, she would have been exposed to the risks of being in hospital including delirium (confusion), infection, and falls. It would not have been reasonable to delay discharge for this, given there was a plan in relation to her not using the stairs unsupervised.
93. We understand this must have been a worrying time for Mr A and his family, especially since he was so concerned about his mother falling again at home. We have made this decision with all this in mind.
94. After careful consideration of the evidence, we have found Mrs A was discharged appropriately.
95. This is because, her medical notes indicate she was medically fit. The evidence also shows she had a care package in place that was designed to fit her care needs, and her home was due to be equipped to provide additional support. This is in line with the NICE guidance above.
96. We do not think it would have been reasonable to keep Mrs A in hospital until her home was fully adapted, as this would have increased her exposure to risks associated with remaining in a hospital environment.
97. To conclude, having considered all the available evidence and with the help of our adviser we have found Mrs A was discharged appropriately. In addition, we have found the physiotherapy assessments were in line with the relevant guidance and that there were no failings in relation to the inpatient fall Mrs A had.
98. We appreciate Mr A has found the events complained about distressing and we acknowledge how difficult this would have been for him to endure.
99. We hope our final report provides some reassurance there was nothing further the Trust should have done to care for Mrs A. We thank Mr A for bringing his complaint to us and we hope we have explained our decision clearly.