Case 14 Falling standards

Mrs Owen is a 79-year-old lady who is partially sighted (macular degeneration), has mild to moderate Alzheimer’s disease, stable heart failure and osteoarthritis of her knees. She lives in an annexe at her daughter’s house and manages to walk short distances within the home but is too unsteady to go out without a lot of assistance. Her daughter takes her shopping once a week in a wheelchair.

Mrs Owen is admitted to hospital with acute delirium resulting from cellulitis of her left leg. She has fallen twice at home in the last 24 hours but without sustaining serious injury. She is seen by a core medical trainee, Dr Manek, who undertakes a thorough assessment and initiates treatment with intravenous flucloxacillin and prophylactic low molecular weight heparin in keeping with local hospital guidelines.

Are there any other areas that Dr Manek should pay attention to?

Mrs Owen’s usual medication is:

Ramipril 5 mg od

Furosemide 40 mg od

Bisoprolol 2.5 mg od

Citalopram 20 mg od

Donepezil 10 mg od

Aspirin 75 mg od

Paracetamol 1.0 gm qds prn.

The staff nurse looking after Mrs Owen tells Dr Manek she is concerned that Mrs Owen is at particularly high risk for falling in hospital and fills out the STRATIFY falls risk assessment tool which she files in the notes. Mrs Owen scores 5/5 on this simple screening tool and so a falls prevention checklist and action plan is completed. Despite being identified as a high risk for falling, Mrs Owen is given a bed in the furthest bay away from the nursing station and although a low bed is advised, none is immediately available. That night, unwitnessed, Mrs Owen gets herself out of bed without asking for help. Predictably, she falls and hits her head on a radiator.

The cover FY1 doctor is asked to review Mrs Owen and he decides the small laceration on her occiput does not require sutures. He reads the notes and concludes she is no more confused than on admission and so takes no further action. The next morning Mrs Owen remains in bed and has to be woken up for breakfast. She seems withdrawn and not at all agitated and perhaps because she is less demanding than on the previous day, the nurse looking after her enters in the notes ‘much more settled today’. The Consultant on-take sees Mrs Owen on the ward round but as he has not met her before he too fails to register that reluctance to get out of bed is unusual for her. The cellulitis is already better and the intravenous flucloxacillin is changed to oral and discharge home within the next 48h is anticipated.

Do you have any concerns about this plan?

Overnight Mrs Owen poses no problems for the nursing staff and she makes no attempt to get up. By the next morning she is very difficult to rouse and Dr Manek suspects she may have sustained a more significant head injury than was initially suspected. An urgent CT scan is arranged which shows a large acute subdural haemorrhage and evidence of a significant mass effect. The regional neurosurgical team is consulted but Mrs Owen’s conscious level falls further and a decision is made not to transfer her for neurosurgery. Three days later she dies without regaining consciousness.

Expert opinion

An internal clinical incident investigation is carried out and the following concerns are raised:

• Although an appropriate assessment of Mrs Owen’s risk of falling was made, no action was taken to address the risk.
  
• After the fall occurred no neurological observations were undertaken to chart and identify the falling level of consciousness.
  
• Staff failed to realize that Mrs Owen’s passivity after the fall was symptomatic of a serious underlying problem.
  
• The late identification of the subdural haemorrhage meant that it was too late to intervene.

This was a preventable death where despite flagging up the risk, no effective measures were put in place. Mrs Owen’s daughter also wrote to ask why her mother had been allowed to fall and the hospital acknowledged its shortcomings and stated it would put in place additional education for all staff to highlight the importance of not just making an assessment of risk but also putting in place appropriate measures to mitigate that risk.

Legal comment

Maintaining accurate clinical documentation as a permanent record of the care provided to a patient is a legal duty. Not only does good documentation ensure a written permanent account of the care provided, it also enables for care plans to be communicated between members of the medical and nursing team and with other members of the multi-disciplinary team.

If the Trust has a protocol and staff have taken steps to document the elevated falls risk, but then failed to undertake practical steps to reduce the risk to the patient, this is something of an own goal. Written evidence-based protocols are to be encouraged, but they must be realistic and achievable or else staff are set up to fail. From the defensibility perspective, the Trust may have been better off without a formal falls risk assessment policy.

The complete absence or paucity of documentation is often a key factor in the assessment of defensibility of a potential claim. To a third party, a lack of information implies the worst. Whereas in reality steps may have been taken to observe a patient (such as Mrs Owens in the account above), if it is not documented in the healthcare records then the courts are able to take the view on the balance of probability the care was not provided and no actions were taken.

The preventable death will be reported to the coroner. Depending upon his views of the factual evidence he may return an accidental death verdict. However, given the findings of the internal investigation that no steps were taken to implement the appropriate care plan as a following on from the falls risk assessment and the documented lack of neurological observations, he is more likely to consider a narrative verdict perhaps with a neglect rider. It is good practice to share the SIRI report with both the family and the coroner prior to the inquest hearing.

The modest damages that would be awarded if breach of duty and causation are proved on the balance of probability would be based on the pain and suffering experienced by Mrs Owen after her fall on the ward until she became unconscious and was subsequently unaware of her condition, in addition to the statutory bereavement award, currently set at £11 800.

Stay updated, free articles. Join our Telegram channel

Join