Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust

8. Mr K complains the Trust did not do enough to prevent Mrs K’s fall on 17 April 2023.

9. He says as a result of the failure to prevent her fall, his mother broke her hip and he believes this resulted in her death.

10. He would like the Trust to make service changes to ensure the same thing does not happen again in the future.

11. Mrs K was receiving radiotherapy and chemotherapy for diagnoses of stage four kidney cancer and lung cancer. She was admitted to the Trust on 5 April 2023 after she became unwell at a radiotherapy treatment.

12. On the morning of 17 April, she fell out of bed.

13. On the same date she had a hip X-ray to investigate pain in her hip after the fall. The X-ray indicated a fracture in her left pubic ramus. This is a fracture in the front pelvic bone. This type of injury will generally typically heal in a few weeks without surgery.

14. She was discharged to a hospice on 21 April 2023.

15. She died on 28 April at the hospice.

20. Mr K is concerned the Trust did not do enough to prevent his mother’s fall.

Assessment and management of risk of falls

21. We have reviewed the national guidance in place at the time of the events of the complaint. NICE CG161 sets out the recommendations for the assessment and management of a patient’s risk of falling in hospital.

22. NICE CG161 says every patient admitted into hospital who is aged 65 or older, should be regarded at risk of falling. As such nursing staff should carry out a multifactorial falls risk assessment.

23. A multifactorial assessment considers the various causes of falling and identifies a patient’s individual risk factors.

24. In this case since Mrs K was over 65, we would expect her to have a multifactorial assessment on admission. From the records she had an assessment both on 5 April in the ED and then again on her transfer to a ward on 6 April.

25. On both occasions, the assessment identified Mrs K’s specific individual risk factors in line with NICE CG16. The assessment concluded she: • had had a fall in the last 12 months • did not have a fear of falling • did not show any signs of cognitive impairment • had some problems with mobility and balance • was prescribed opiate medication.

26. The latter point is significant since this type of medication increases the risk of falls because they may cause sedation, dizziness, impaired balance and coordination.

27. NICE CG16 says that a multifactorial assessment may also include an assessment of mobility. From Mrs K’s records dated 6 April nursing staff also completed a moving and handling assessment to assess Mrs K’s level of mobility. This found she: • needed assistance to stand up and to walk and to use the toilet • could not walk further than 50 metres due to shortness of breath • could move unassisted in her bed.

28. CG61 goes onto recommend that after the assessment, nursing staff should set up multifactorial interventions to manage the identified risk factors.

29. We have looked at what nursing staff did in Mrs K’s case to manage her risk factors.

30. On 6 April at the time of her admission to the ward, nursing staff put in place a care plan to address her risk of falls. From the care plan nursing staff: • would nurse Mrs K in a bed that was within easy observation of staff and also close to the bathroom to reduce the distance she had to walk to use the toilet • leave her bed at the lowest level • make sure that frequently used items such as her glasses, drink etc were left within easy reach • make sure she could reach the nurse call bell and knew how to use it • make sure they did not leave her unassisted on a commode or toilet • would carry out intentional rounding every hour.

31. Intentional rounding refers to the planned regular checks nursing staff carry out on a patient. The checks may include re-positioning, skin assessment, checking the patient is not in pain or whether they need a personal item or want to use the toilet.

32. The care plan also referred to the requirement for a bed rail assessment. We have looked at the guidance for a bedrail assessment.

33. There is no national bed rail assessment tool. For information, however, since 1 March 2024 all local Trust bed rail assessment tools have to comply with the national safety guidelines set out in the Medicines and Healthcare products Regulatory Agency (MHRA).

34. At the time of the events of this complaint Gov.uk guidance: Bed rails: management and safe use, March 2020 (Gov.uk guidance) set out the guidelines for this type of assessment. It explains the purpose of the assessment is to balance the benefits of bedrails with the potential risks. For example, a patient with dementia might not understand the purpose of the rails, which could increase the risk of injury.

35. From Mrs K’s records, the Trust completed a bedrail assessment on three occasions. The first was on the date of her admission and the third was the day before her fall.

36. The assessment on each occasion said: • she was orientated and alert • she had impaired mobility • she was not likely to fall out of bed • a bed rail could not increase any risk to her clinical condition • she did not have a confirmed dementia diagnosis • she was nursed on a bed rather than a trolley.

• she had some repetitive involuntary movements 37. The Trust explains that the involuntary movements in Mrs K’s case were myoclonic jerks. Myoclonic jerks are sudden, brief, involuntary muscle twitches or spasms.

38. The Trust explains that the above factors gave her an overall score of 11 which indicated that bedrails were the most appropriate safety measure for her. It has commented that arguably the assessor could have arrived at the conclusion that she was likely to fall out of bed due to her myoclonic jerks. This would have increased the overall score but would not have changed the recommended intervention.

39. From the above evidence it appears that the Trust carried out a bedrail assessment in line with Gov.uk guidance relevant at the time. This is because we can see the questions were designed to determine the balance of risk and benefit of bedrails in Mrs K’s case.

40. We note that nursing staff created a mobility care plan which addressed her need for assistance when standing up and walking. Mrs K was referred to the physiotherapist and occupational therapist for further assessment who agreed she was fit to mobilise with assistance. The ongoing plan was to monitor her mobility, address any anxieties she felt about mobilising including fear of falling and to provide assistance with mobilising. The plan said she needed the assistance of one person to go to the bathroom.

41. From our review of the available evidence, it appears the Trust complied with CG161 in its assessment and management of Mrs K’s risk of falling. This is because we have seen the Trust correctly treated her as at risk of falls due to her age and carried out a multifactorial assessment accordingly. We have also seen the Trust implemented care plans as set out above to address her risk factors, and we have seen evidence in the records that these were regularly reviewed from the date of her admission up until the time of her fall.

42. There is nothing in the care plans which refers to any need for supervision during any time Mrs K was in bed. Our adviser explains that this is because she had capacity and she understood how to use the nurse call system. The risk of falls care plan and the daily orientation assessment both refer on regular occasions to Mrs K understanding how the call bell worked.

43. This is also in line with NICE CG61 which says that any multifactorial interventions should consider the patient’s ability to understand and retain information about asking for help before getting up, moving around etc and provide consistent messages to the patient accordingly.

Mrs K’s fall on 17 April 2023 44. As explained elsewhere, Mrs K needed one person to assist her out of bed and walk to the toilet. She understood how to use the call bell to alert nursing staff when she needed this assistance. Mr K has also confirmed to us that his mother always rang the bell when she needed to do go to the bathroom.

45. This appears to have happened without any issues until the 17 April.

46. The Trust incident form says a member of the domestic staff (the domestic) saw Mrs K shuffling down the bed at 7.45am. Mrs K asked the domestic for help to go to the bathroom. The Trust have explained that the domestic had not received any training to provide any care to patients and therefore they went to find a nurse to help Mrs K. The Trust say two health care assistants immediately attended Mrs K once the domestic alerted them. However, when they arrived at Mrs K’s bed, she was on the floor, and it appeared she had fallen out of bed through the rails.

47. We note the Trust took statements and spoke to any staff involved in order to establish what happened.

48. We know Mr K is not confident that the explanation he received is correct. We understand this is because initially ward staff gave him different accounts of what had happened. However, we are satisfied that the Trust’s investigation was thorough and we have no reason to doubt its account and explanation. This is particularly since it has accepted responsibility for what happened and was critical of the care it had provided.

49. As such we accept the Trust’s account of what happened and we also acknowledge that what happened is not what should have happened.

50. It is not disputed that the domestic’s decision to leave Mrs K unattended was an error. It therefore indicates there was a failing in the care provided. This is because our principles of good administration expect all public organisations to provide effective services with appropriately trained and competent staff.

Impact

51. Mr K says the fall caused his mother’s subsequent death. He has explained why he thinks this is the case.

52. We know from Mrs K’s records that the fall resulted in a fracture in her pelvis. We understand from Mr K that some days later she had a catheter inserted. This was because she was in too much pain to walk to the toilet as she had previously been able to do. Mr K believes the catheter resulted in a urine infection. He believes the urine infection caused her death in the hospice and therefore this could have been avoided if she had not fallen out of bed.

53. We have carefully considered Mr K’s concerns.

54. We note Mrs K was very unwell already at the time of her fall. She had been receiving chemotherapy and radiotherapy and was under the care of a cancer specialist for both kidney and lung cancer. She was already under the palliative care team and on IV antibiotics for neutropenic sepsis. Neutropenic sepsis is a life-threatening medical emergency that occurs when someone with a very low white blood cell count develops a severe infection. It frequently affects cancer patients undergoing chemotherapy.

55. We also note Mrs K died a few days after her discharge to the hospice. We have not looked at Mrs K’s received at the hospice prior to her death since this is not part of Mr K’s complaint.

56. We do not think that further investigation on our part could establish a causal link between the fall and Mrs K’s death. This is because of the complexity of the clinical situation and the number of possible contributing factors. For instance, we would not be able to determine, with any degree of certainty, how Mrs K acquired any infections, or precisely when she acquired them. Without being able to do that, it will not be possible to establish that events unfolded in the way that Mr K believes they did.

57. We do however recognise the circumstances of Mrs K’s fall caused Mr K significant distress at a very difficult time and continues to affect him now.

58. Where we see that someone did not receive the standard of care they had the right to expect, our role is to determine whether the Trust has already done enough to try and put things right.

59. We are pleased to see the Trust has provided an explanation of what happened and apologised to Mr K or the mistake that was made.

60. One of the outcomes Mr K was seeking from us was service improvements to ensure the same thing does not happen again. We have seen evidence that the Trust has made those service improvements already. The Trust says the domestic supervisor has now advised the domestic team that they must stay with a patient if they think they are at imminent risk of falling and use the call bell to get assistance.

61. We have reviewed the actions the Trust has taken. We are of the view that they are reasonable, and the service changes are sensible and proportionate. In the future, domestic staff should have a better understanding about how to maintain patient safety in this kind of situation, so there is less chance of the same thing happening again .

62. As such we consider the Trust has done enough to put right the upset caused to Mr K and achieve the outcomes he seeks.

63. We understand the circumstances of his mother’s fall have been very distressing for Mr K. We hope our consideration reassures him the Trust has made effective changes to try to stop the same thing happening again.

1. We have carefully considered Mr K’s complaint about Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust (the Trust).

2. We are sorry for his loss and to hear about the sad events of his mother’s last days in hospital.

3. We agree with Mr K’s view that the Trust did not do enough to prevent his mother’s fall on 17 April 2023. This was accepted by the Trust at the time.

4. We are sorry Mr K believes the fall resulted in his mother’s death. We do not feel any further investigation by us would be likely to shed any light on this for him. We have explained more about this later in our report.

5. We acknowledge nonetheless that what happened caused Mr K upset and distress.

6. The Trust has apologised to Mr K and explained how the failing in care happened. It has also made service changes to try to make sure the same thing does not happen again.

7. We are satisfied that this is enough to put right things right and as such we will not take any further action here. We have explained how we have arrived at our decision in more detail below.