Mid Yorkshire Teaching NHS Trust

4. Mr S complains about the lack of care provided to his father, Mr H, by Mid Yorkshire Teaching NHS Trust (the Trust), which resulted in a fall on 6 June 2023.

5. He says the avoidable fall resulted in his father sustaining severe injuries, which included a fractured skull, broken eye socket, and broken jaw. He needed 21 stitches to his head/face.

6. He says the fall resulted in his father’s death later in June. Further, it has resulted in long lasting psychological impact on him and his family.

7. As a result of complaining to us, he is seeking:

• an acknowledgement of failings • a written apology • service improvements • financial redress.

8. This background is intended to place the key events in context, not to provide a full account of everything that happened.

9. Mr H attended the Emergency Department at the Trust on 20 April 2023 for limb problems and injuries following a fall at home. His diagnosis was ‘vasovagal syncope’ (a common type of fainting from reduced blood flow to the brain) and ‘recurrent falls and head injuries’. Staff noted he had recurrent falls and head injuries three times in seven days. They admitted him to hospital.

10. On 12 May, staff transferred Mr H to an intermediate care unit at the Trust, for physical therapy to improve mobility before discharge.

11. On 6 June, Mr H had an unwitnessed fall from the chair next to his bed. A nurse entered the bay and found him lying face down and unresponsive on the floor in front of his chair. The nurse requested urgent assistance and an ambulance. He sustained a cut to his forehead and facial injuries. The ambulance crew attended and transferred him to the Emergency Department at a different hospital.

12. Later in June, Mr H sadly died.

16. Mr S has raised concerns his father’s fall could have been avoided, if the Trust provided adequate care and support.

17. To establish what should have happened during Mr H’s admission, we have reviewed the NICE guidance. It says, ‘older people who present for medical attention because of a fall or report recurrent falls in the past year or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment’. This guidance applies because Mr H was admitted to hospital following a fall at home and was noted to have recurrent falls.

18. The guidance says at 1.2.2.3 ‘ensure that any multifactorial assessment identifies the patient’s individual risk factors for falling in hospital that can be treated, improved or managed during their expected stay. These may include: • cognitive impairment • continence problems • falls history, including causes and consequences (such as injury and fear of falling) • footwear that is unsuitable or missing • health problems that may increase their risk of falling • medication • postural instability, mobility problems and/or balance problems’.

19. In line with the above guidance, the Trust carried out a falls risk assessment on 20 April on Mr H’s admission to hospital. It decided he was at high risk of falls and noted he had poor mobility due to ‘unsteady, poor balance, and uses walking aid’. The Trust noted he was known to have previous falls in the last 12 months, has difficulty walking or balancing, and has a fear of falling. It noted he was not confused or disorientated and admitted him to a particular ward due to falls.

20. The Trust carried out further falls risk assessments on 5 May, 9 May, 12 May, 19 May, 26 May, 28 May, and 2 June. We have carefully reviewed each risk assessment. We have found these assessments were in line with the above guidance. The records show it considered factors such as his falls history and fear of falling, as well as assessment of any cognitive impairment.

21. For example, we can see it recorded Mr H had a fear of falling and noted he was taking four or more medications which increased his risk of falling. It also considered if he had poor vision or hearing and noted he wears glasses and has a hearing aid.

22. NICE guidance at 1.2.2.4 says ‘ensure that multifactorial intervention promptly addresses the patient’s identified individual risk factors for falling in hospital and takes into account whether the risk factors can be treated, improved or managed during the patient’s expected stay’.

23. The falls assessments show the Trust put measures into place to manage the falls risk. The measures included non-slip slippers, bed rails, ensuring the call bell was within reach, assistance whilst walking, and assistance when visiting the toilet. It also placed a falling star above his hospital bed (this is a visual symbol used in hospital to show the patient is at high risk of falling).

24. This demonstrates how, during the first part of Mr H’s admission, the Trust appropriately managed Mr H’s risk of falling in line with the guidance, as it put measures into place to mitigate the risk.

25. We have noted that Mr H presented with confusion, particularly later in his hospital stay. On 29 May, the therapy team had noticed some confusion. On 30 May a nurse noted he had been incontinent of urine (unintentional passing of urine) and on 1 June there was some overnight intermittent confusion documented. On 2 June, the Trust noted Mr H as ‘confused’ in the falls risk assessment.

26. Mr H’s confusion seemed particularly concerning on 5 June, as he was noted as agitated as he believed a meeting with a social worker was due to take place at 10.30pm. The notes say a nurse had to reassure him that he would not be attending any appointment at 10.30pm.

27. The Trust said Mr H was still anxious about a meeting with a social worker on the morning of 6 June. The records say ‘he was wanting to get up and sit in his chair, advised patient that it is better for him to stay in bed a little longer but patient wanted to get up, assisted patient into his chair. He was then assisted with a urinal at around 7am patient had unwitnessed fall with head injury’.

28. The records say following the fall, ‘patient had an unwitnessed fall this morning, colleague was completing documentation, patient was assisted into the chair, where he is usually settled and does not attempt to mobilise. Call bell to hand, non-slip socks worn at time of incident. My colleague heard a bang, and he was found face down on the floor’. It states the fall was ‘not observed’ and from ‘walking/slip’.

29. The Trust has explained on 6 June, when Mr H was sitting in the chair, the health care assistant went to get a chair sensor mat (a safety device placed under a chair cushion to alert caregivers when a person at risk of falling leaves their seat).

30. Our findings on what happened, from the evidence available, is it is likely Mr H attempted to get out of the chair whilst unsupervised. We consider this led to his fall, as he was confused and at high risk of falls.

31. The contributory factors to the fall were documented as ‘patient assessed as being at risk of foreseeable falls, patient has been on the ward for more than one week, staffing levels normal for the ward at the time of the incident, unexpected activity or movement (confused, wandering etc)’. It says the actions taken to prevent or minimise harm were ‘advised not to get out of bed and use buzzer, alarm insitu, enhanced care implemented’.

32. The focused assessment record states ‘usually confused, unwitnessed fall this morning, fell off chair, staff report loss of consciousness (LOC) for a couple of seconds, self-resolving, hit head and sustained injuries to face (laceration to forehead and bridge of nose, swollen top lip, and right forearm’. At my review, Mr H informs me he can’t remember the fall or what happened afterwards’.

33. We have carefully considered Mr S’s complaint and the supporting information he provided. We also considered the information in the records and the advice we received.

34. NICE guidance recommends ‘individualised interventions are considered when aiming to reduce the risk of patients falling’. Our adviser’s view, which we agree with, is when Mr H appeared to be confused, enhanced supervision was needed. This is because the risk of him falling was heighted.

35. We understand Mr H often sat in the chair during his hospital stay with no previous concerns before this, other than on 14 May when he was noted to be slipping from the chair.

36. The Trust has acknowledged it should have carried out delirium screening. It said this should be undertaken on admission, on transfer, and when acute confusion is observed.

37. When Mr H presented as confused and had concerning symptoms particularly on 5 June, our finding is the Trust should have undertaken delirium screening. This was necessary to meet the NICE guidance as there was potentially a further problem relevant to the risk of falling. It did not do this, and is a failing in the care it provided.

38. The Trust’s policy on enhanced care defines three levels of observation, which are applied following individual risk assessments. The three levels are as follows:

• intermittent observations – at risk of falls and getting up unaided, increased clinical need, mild confusion, sometimes restless and agitated. The patient must be observed at specific intervals • line of sight observations – high falls risk, confused and/or at risk of absconding, risk of pulling out any medical devices, agitation/anxiety/reduced insight. The patient must be visible and under constant, uninterrupted supervision of the observer. This will be within line of sight and staff will be close enough to respond immediately should an incident occur or be likely to occur • arm’s-length observations – presenting risks to self and others, violent behaviour and aggression to others and self, expressing intent or recently attempt to self-harm or suicide ideation. The patient must be subject to close proximity, constant uninterrupted observation.

39. Our finding is that it is more than likely delirium screening would have shown Mr H required enhanced supervision. This is because of the confusion symptoms he presented with, along with high risk of falls.

40. The Trust has since acknowledged that consideration of line of sight observation may have been appropriate. After careful review, our finding is Mr H more than likely required line of sight observation, from around 5 June. This is because he was at high risk of falls and had concerning confusion symptoms.

41. The Trust failed to take appropriate fall prevention measures in line with its policy prior to his fall. This is a failing.

Findings on impact 42. We have carefully considered the impact of the failings in the management of Mr H’s risk of falls.

43. Mr H unfortunately suffered severe injuries as a result of the fall. He sustained a laceration to his face and an X-ray found he had a facial fracture and a basal skull fracture. We were sorry to hear about this and understand how distressing this must have been for Mr H and Mr S.

44. Mr S says the fall led to his father’s death. We acknowledge his view on the impact this fall had. We understand why he has this view given his father suffered a head injury and sadly died approximately two weeks later.

45. We have reviewed BJN information. Its article explains a study showed during 2022, 314 falls were reported within a division (part of a large hospital Trust in the UK). 61 falls occurred whilst under enhanced supervision, and 23 took place when the patient was due to be under one-to-one supervision. This shows that enhanced supervision or one-to-one supervision does not remove the risk of falls entirely.

46. We obtained input from our adviser. Their view, which we agree with, is the fall could have been prevented if a staff member was present whilst Mr H was sat out in the chair.

47. Line of sight observation could have provided the Trust with the opportunity to prevent him from falling. This is because a staff member would have been close enough to respond when he fell.

48. We cannot say for certain that enhanced observation would have prevented the fall. This is because, sadly, even with interventions in place falls can still happen. This is evidenced in the article in BJN, outlined above.

49. It is difficult to be certain on the impact because we do not know exactly how the fall happened. Presumably, Mr H tried to get out of the chair and fell as he was found facing down on the floor. This could have made the fall difficult to prevent, but we do not know for certain.

50. We have carefully considered this and we cannot say, even on the balance of probabilities, enhanced supervision would have prevented Mr H’s fall.

51. Our finding is it was inappropriate for the Trust to leave Mr H unsupervised whilst sat in the chair as he was confused and at an increased risk of falling. We consider enhanced supervision could have provided the opportunity to prevent the fall or make the fall gentler. Our finding is the risk of harm from suffering a fall was increased due to the failing we have identified.

52. The failing led to Mr S’s significant distress in relation to his father’s care. We can only imagine how Mr S must have felt following his father’s fall and are truly sorry to hear about what happened. We also recognise the pain and distress the fall would have caused Mr H at a time when he was already confused and unsteady.

53. We have not identified enhanced supervision would have changed the sad outcome, because the fall may have still happened for the reasons outlined above. In turn, we cannot say Mr H’s death was preventable.

54. The Trust, in its response, said it did not consider there were any lapses in care. It said it could have consciously considered delirium, and this may have prompted consideration for a medical review. It said the Trust Delirium guidelines are currently being updated to include more frequent completion of the 4AT rapid clinical test for delirium detection. This is a screening instrument designed for rapid and sensitive initial assessment of cognitive impairment and delirium.

55. This is not enough to put right the failings. We have set out our recommendations below.

1. We were sorry to hear about the incredibly distressing time Mr S has experienced and offer our sincere condolences on the sad loss of his father, Mr H. We also recognise the fall must have been painful and distressing for Mr H.

2. Our investigation has found failings in the Trust’s management of Mr H’s risk of falls. Our view is this would not have changed the sad outcome. This led to an increased risk of harm and added to Mr S’s understandable distress in relation to his father’s care.

3. We are partly upholding the complaint. We recommend the Trust acknowledges the failing and implements service improvements. We also recommend the Trust apologises to Mr S and pays him £600 in recognition of the impact the failings had on him.