Trust failed to take action to prevent older woman falling in hospital

What happened

The Trust identified Mrs F as being at a high risk of a fall but it did not put in place a falls risk plan on her transfer to another ward five days later and no discussion about her falls risk took place between the staff. Further, the Trust did not carry out an assessment of falls risk in the second ward. Mrs F then fell while trying to move from the commode to her bed, fracturing her hip and bruising the side of her head. Mrs F's family were not told about the fall and her daughter only found out about it when she visited her mother later that day. Mrs F's condition deteriorated rapidly and she died three days later.

The Trust produced a serious incident requiring investigation (SIRI) report, which concluded that the fall could have been prevented. It did not share this with Mrs F's daughter and the complaint responses did not fully reflect the conclusions of the SIRI report.

What we found

The Trust was not as open as it should have been following Mrs F's fall. The fact that the SIRI report was not shared and its conclusions not fully reflected in the complaint response left the family with unanswered questions.

It was appropriate to leave Mrs F on the commode in privacy, but the Trust failed to take sufficient action to minimise the risk of a fall. There were also failings in communication with the family. The fall was likely to have contributed to her deterioration and death.

However, it was not the sole cause and Mrs F received appropriate care after her fall.

Since the time of these events, the Trust has taken action to improve the standard of nursing care, falls risk assessment and care planning, ward leadership and communication with patients and relatives.

Putting it right

The Trust has apologised for failing to take appropriate steps to minimise the risk of the fall. It has also agreed to apologise for not sending the SIRI report to Mrs F's daughter and that its complaint response did not fully reflect the conclusions of that report. It has sent the family the SIRI report and information about all the actions it took as a result.