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June 14th 2021

Hospital Negligence

Failures in hospital care put focus on how to prevent frail, confused patients falling

Kirsty Yates

Kirsty Yates

Litigation Executive, Clinical Negligence

Failures in hospital care put focus on how to prevent frail, confused patients falling

Failures in the hospital care received by a 92-year-old woman have highlighted important lessons around how to treat patients with Alzheimer’s disease and mobility issues.

Failures in the hospital care received by a 92-year-old woman have highlighted important lessons around how to treat patients with Alzheimer’s disease and mobility issues.

The woman had been living independently in her sheltered flat and enjoyed attending dance classes before she was taken to hospital on September 19, 2017 due to reduced mobility after suffering a series of falls.

She was placed on a ward but despite her history of confusion at night and an issue with night-time wandering, it was then decided to transfer her to another ward at midnight.

At around 6.20am, the woman, who was struggling with hip pain, tried to leave her bay unassisted and fell. An X-ray confirmed she had suffered a fracture to her left wrist, which needed surgery that same day.

The injury subsequently left the woman, who is now 96, needing an aid to move around and reduced mobility. Despite healing well, she has been left with permanent tenderness to the wrist.

In January 2018, she was then readmitted to hospital with difficulty breathing and was diagnosed with a bilateral pulmonary embolism.

She made a full recovery but now, due to an exacerbation of her Alzheimer’s, the woman has been unable to return to independent living and lives in a residential centre where she requires more care and support.

Kirsty Yates, litigation executive in clinical negligence at Hudgell Solicitors, helped the woman make a hospital negligence claim against the Bolton NHS Foundation Trust, Lancashire, over failures in her care while in hospital.

Ms Yates said: “An expert geriatrician advised that a prolonged period of mobility difficulties which related to her inability, due to her wrist injury, to use a walking stick or wheeled frame to assist her keep mobile was the main risk factor for the pulmonary embolism she suffered.

“They noted that her fall and subsequent injuries likely exacerbated her need for residential care by four to six months.”

Hospital negligence claims – Findings highlight issues in care

A detailed root cause analysis (RCA) report by the Bolton NHS Foundation Trust into the circumstances around the fall and transfer to a different ward at midnight highlighted numerous failures, including the nurse-to-nurse handover process being incomplete; and the ward being one health care assistant short for that night shift.

Ms Yates added: “An independent nursing consultant advised us that best practice would strongly recommend that a patient with Alzheimer’s disease should not be transferred to an alternative ward in the middle of the night as this is only likely to enhance their confusion and distress.

“They said it would be reasonable to transfer such a patient if the ward was fully appraised of the woman’s needs as part of the nursing handover and had sufficient nursing resources.

“Unfortunately, not only was the receiving ward not appraised of our client’s confusion, as well as her risk of falling, but the receiving ward was also not provided with the critical nursing assessment documents that had been completed on the previous ward.

“As a consequence, it would appear that the nursing staff did not implement any reasonable measures aimed at preventing her falling, especially as she had a history of falling.”

NHS complaints – Trust admits breaches of duty

The RCA report also found there were other patients who were more appropriate to transfer; the woman had not been assessed as a suitable patient to transfer as she required an outstanding X-ray; and she was placed into a bed at the far end of the ward that was not observable on a ward that had insufficient nursing resources to manage her complex needs to be able to check on her hourly.

Ms Yates added: “The nursing expert concluded that had reasonable measures been implemented aimed at preventing the woman from falling, on the balance of probabilities, the fall would not have occurred.”

The Trust admitted that several breaches of duty led to the woman’s fall, fractured wrist, surgery, prolonged stay in hospital and subsequent care at Darley Court to aid with her rehabilitation.

It remained silent in respect of the exacerbation of the Alzheimer’s disease, pulmonary embolism and permanent tenderness to the wrist, but agreed damages of £27,000.

Hospital negligence cases – Lessons learned and what should have happened

The independent nursing consultant advising Hudgell Solicitors said lessons can be learned from this case and issued the following nursing actions that should be in place in such a scenario:

  • A confused patient at risk of falling should not be transferred to an alternative ward at midnight when there is insufficient resources to meet their needs and where there is an absence of a high visibility bed in order to closely observe them following the transfer.
  • For confused patients like this, orientation should be an ongoing process.
  • On a regular basis, alert the patient and their family of the fall prevention interventions in place.
  • Communicate the patient’s ‘at-risk status’ at each nursing shift/ward handover.
  • Provide a commode at the bedside if deemed appropriate.
  • Undertake and document a lying and standing blood pressure in order to rule out postural hypotension as a possible risk of falls.
  • Provide nursing supervision appropriate to the risk of falling. This would include, at a minimum, hourly rounds or would require introducing 1:1 continuous nursing supervision at times when the patient is observed to be agitated and confused.
  • Ensure that the bed was in the lowest position possible. If available, utilise an ultra-low bed which can lower almost to ground level.
  • Remove all obstacles and clutter and other unnecessary equipment and furniture.
  • Consider placing crash mats alongside the patient’s bed in order to reduce the likelihood of an injury occurring should they attempt to mobilise without the support of nursing staff.
  • Utilise an electronic movement sensor alarm which will detect and emit an alarm if the patient attempts to mobilise independently from their bed or chair.
  • Ensure that the patient is positioned in a high-visibility area of the ward.
  • Ensure that there are sufficient nursing staff available to provide the necessary levels of supervision.

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