Serious Patient Fall at a DCHSCommunityHospital
Patient Story;
Patient A, a 71 year old gentleman, had been admitted to one of DCHS’s Community Hospitals from the Emergency Admissions Unit at CRHFT in Spring 2009.
He had a diagnosis of Parkinson’s disease, and whilst at home had been under the care of a Consultant Physician, and attended the Movement Disorder Clinic.
The Multi Disciplinary Team (MDT) notes indicate that there had been deterioration in Patient A’s overall physical and mental condition; “…over the past few weeks” whilst at home, prior to admission. The physiotherapy initial assessment, 15.5.09 noted Patient A “sustained injuries in a fall at home”). It is unclear from the notes if the increased falls experienced whilst at home occurred repeatedly in the same day or over a series of days prior to admission.
Throughout Patient A’s admission to DCHS’s CommunityHospital ward it is evident from the M.D.T. notes that his level of mobility varied. At times described as “good” and at others as “slow” and as having a “shuffling gait”. He did not experience any falls up until1st June 2009.
The first fall on that date occurred at approximately 13.40 hrs. when staff were alerted by a noise in cubicle F.
Patient A was found lying on his right side with no loss of consciousness. The nursing staff who attended to him noted that he was alert and responsive, but that he had sustained an abrasion to the top of the right side of his head. It was reported that neurological observations were commenced, and recorded on a DCHS Community Hospital Neurological Observations chart .
According to the staff who were interviewed in relation to this incident, following this fall, Patient A remained on his bed and was visited by his wife.
Neurological observations were reportedly continued over this period.
At approximately 18.15 hrs. Patient A experienced a second fall. This occurred whilst Patient A was in the day room.
Nursing staff were alerted by visitors and the noise they heard as Patient A’s head made contact with the wall.
Attempts were made to maintain his airway, and staff summonsed paramedic assistance by dialling ‘999’. Patient A was transferred to CRHFT, and a member of the nursing team phoned ahead in order to alert CRHFT of his imminent arrival. Unfortunately Patient A did not recover. He died June 2009.
The incident was registered as a Serious Untoward Incident, and a full investigation was undertaken. The investigation found several areas where further development and action was required and made clinical and environmental recommendations. The investigation also identified many areas of excellent practise, and concluded;
“….the investigating team were charged with looking at the circumstances surrounding this fall, and it has been demonstrated that Patient A received a high standard of care throughout his admission to the ward. On the balance of evidence seen to date, this incident occurred despite the best efforts of the staff. Until the date of Patient A’s fall, staff had done all they reasonably could to ensure he did not sustain any falls. It is the investigating team’s conclusion that this was an unexplained accidental fall.”
However, it is important to note that Patient A was not just “a patient”, a collection of diagnoses or “an incident”. He was a husband and father, and his family were left devastated by his loss. In an attempt to provide some answers to questions they may have regarding the fall, DCHS’s Assistant Director of Quality and Integrated Governance offered to meet with Patient A’s family, to which his son and daughter accepted.
During the meeting, Patient A’s daughter explained that their mother was too upset to attend the meeting, and had no cause for complaint regarding Patient A’s care. However both Patient A’s son and daughter had lots of questions regarding the incident, namely “why couldn’t something have been done to prevent it?” They were both dignified and reasonable in manner, but there was an undercurrent of anger, raw emotion and a huge sense of bereavement. Patient A’s son stated that he worked in a particularly dangerous industrial environment, and “if I saw a colleague was about to fall/injure himself, I would do everything in my power to prevent any harm coming to him”
Patient A’s daughter agreed that she would like to see a copy of the final report once completed, and her comments included:
“….I do still maintain there was an element of negligence which was contributory to his ‘unexplained accidental fall’. This is all the harder to accept when, in my mother’s words, she ‘pushed to get him admitted into hospital to be safe’. Her concern for his safety was due to the fact that she had building work taking place at home and, as he had already fallen at home due to his low blood pressure, she was particularly concerned that he was able to be looked after in a safe environment.”
“The most serious omission in the report though is the lack of knowledge of other falls that he sustained throughout his stay in hospital. Whilst I can’t give you precise dates I remember conversations of at least one and possibly two other falls before his final day with you on 1st June. I would conclude that this shows a lack of adequate record keeping, recording and communication between staff.”
These comments leave no doubt that, in the eyes of this family, the care provided on this occasion was not of an acceptable standard. Patient A’s daughter’s closing comments were;
“…I am pleased to see that you are considering improvements which should help patient safety, but I feel I have to tell you that my family and I do feel that there was an element of staff negligence which contributed to my father’s wellbeing and fatal fall “
Please feel free to share this letter with any relevant colleagues, senior managers and governors as appropriate.”
The challenge this patient story now presents DCHS is clear. Have the recommendations made by the report following the investigation been fully implemented and communicated to all those providing care for individuals who are at risk of falling?
Jane Stone
Clinical Governance Advisor
January 11th 2010