Pauline Hayston

1. The deceased had correctly been assessed as presenting a high risk of falls as an inpatient on ward and nursing staff accordingly were to deploy the use of a Rambleguard falls mat. The evidence established that it was correctly positioned.

. The Rambleguard falls mat failed to activate upon the un-assisted mobilising of this patient. Evidence from the Ward Manager and Nursing Staff established that: a. The wireless “WiFi” activated system would frequently cause a significant delay as between a patient activating the signal and the transmission to nursing staff.

b. There had been at least 4 occasions within the experience of the Ward Manager that the Rambleguard fall mats were not activating at all - in circumstances that suggested to the Ward Manager that the mats were not fit for purpose.

c. The mats had been returned to the manufacturer who were unable to establish why the fall mats had not been activated.

d. The issue of the time delay between activation and the triggering of the nursing alarm was considered by the manufacturer, potentially, to be because of an interference of the signal arising from the number of mats in use in one Ward, but there was no evidence that nursing staff had been given instruction or guidance as to how resolve this potential technical operational issue.

The evidence raises the following concerns:-

. The reliability of the Rambleguard fall mats and its fitness for purpose. . The suitability of a wireless “WiFi” activated on a ward where several fall mats are in place in close proximity to each other. . Interim instructions to nursing staff where the operational integrity of an essential item of equipment to alleviate falls risks has been identified.