Fall in hospital led to fractured hip

What happened

Mr D went into hospital complaining of hip pain after he fell from a chair at home. Staff diagnosed delirium and treated him successfully, but he fell while unattended and fractured his hip.

What we found

The Trust did not carry out a mobility assessment. As this was not done, Mr D should have received safe support while standing. We cannot say that the fall could have been prevented and the fracture avoided if staff had been with Mr D.

We also saw a failing in that Mr D was placed in a chair after his fall, despite a note that he was complaining about hip pain. It is likely that this caused him additional pain and discomfort.

Although the Trust acknowledged that staff should have carried out a mobility assessment, apologised and took some corrective actions, we felt it could do more to stop similar problems happening again.

Putting it right

The Trust apologised to Mr D, accepted that it was not best practice to put him in a chair after his fall, and paid him £200 compensation. It also took steps to emphasise the need for medical staff to clearly keep details of a patient's mobility management plan in the clinical records. It also found ways to monitor the effect of these improvements.