Trust failed to carry out risk assessment designed to prevent injury to a patient

What happened

Mrs B was an inpatient at the Trust. She suffered from dementia as a result of Parkinson's disease and a haematological condition meant she injured easily. During her stay at the Trust she injured her leg.

Mrs B gave three separate accounts of the cause of her injury, which happened while she was alone. This included falling, hitting her leg and trapping her leg in the bed rails.

Mrs B's husband believed the final explanation was the cause of his wife's injury and complained that the bed rails should have been protected.

What we found

It was not possible to find the cause of Mrs B's injury. We established that the injury most probably happened when Mrs B tried to get out of her bed unaided and that she could have hurt herself on many different parts of her bed. However, it was clear that a bed rail risk assessment had not been carried out during Mrs B's stay.

Putting it right

The Trust acknowledged its failings, apologised to Mr B and paid him £250 in compensation. The Trust carried out a serious event investigation and acknowledged that Mrs B should have had padded bed rails to provide better protection from injury. The investigation also identified areas for training. The Trust's risk management committee also agreed to obtain better bed rail protection for use by patients considered to be at risk of injury and supported by a risk assessment.