North Cumbria Integrated Care NHS Foundation Trust

4. Ms K complains about aspects of care and treatment her partner, Mr T, received from North Cumbria Integrated Care NHS Foundation Trust (the Trust) between November 2023 and January 2024.

5. Specifically, Ms K complains the Trust failed to prevent Mr T’s multiple falls.

6. Ms K says this put Mr T at higher risks of falls and injuries. This caused Ms K distress.

7. By bringing this complaint to us Ms K is seeking an acknowledgement of what went wrong, service improvements to prevent similar experiences and financial remedy.

8. Mr T was over 80 years old at the time of events.

9. On 4 November 2023, Mr T experienced a fall. The Trust admitted him to hospital and discharged him home later the same day. The Trust conducted imaging which found Mr T had a collection of blood on the surface of his brain pushing the brain off its central position.

10. The Trust planned to repeat imaging within seven to ten days initially, but Mr T deteriorated at home and he attend the Trust again on 7 November.

11. Mr T was an inpatient for a total of eight months and transferred to several different hospitals across two separate trusts.

12. Sadly, Mr T died in late July 2024 whilst an inpatient at the Trust’s rehabilitation hospital.

16. Ms K complains the Trust failed to prevent Mr T’s multiple falls.

17. The Trust set out the steps it took to manage Mr T’s falls. These included: • a falls risk assessment management plan (FRAMP) • call bell to alert staff when he needed assistance • a bed as close to the nurse station as possible • falls sensor • high-low bed • physiotherapy • advice to mobilise with zimmer frame • and lying and standing blood pressure assessments.

18. The Trust said even with preventative measures put in place, it could not guarantee all falls will be prevented, despite its best efforts.

19. NICE CG161 says clinicians should regard all patients aged 65 years or older as being at risk of falling in hospital. It also says older people who present for medical attention because of a fall, should be offered a multifactorial falls risk assessment.

20. This guidance says ensure 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.

21. Ms K told us she is specifically concerned about the falls management at a specific hospital which is part of the Trust. Mr T was an inpatient at this hospital between 10 November to 21 November 2023 and 1 December to 3 January 2024.

22. As such, we have considered the Trust’s management of Mr T’s falls risk for each of these two admissions, with the help of our nursing adviser.

10 to 21 November admission

23. On Mr T’s return to the Trust’s A&E on 7 November, the records show it conducted a falls care plan, as his admission was due to a fall. This indicates Mr T was anxious about falls, tries to walk alone but was unsteady/unsafe, requires assistance to go to the toilet, taking medication which could increase falls risk, and appeared agitated or confused. The admission records also show Mr T had dementia.

24. Following Mr T’s transfer, the Trust used FRAMP. The Trust’s falls policy states FRAMP is the risk screening and falls prevention and management tool used in all inpatient areas. FRAMP contains all the identified predictors of falls risk and is tailored to meet the needs of each individual patient. It also facilitates a shift by shift check of interventions in place to minimise the risk of falling.

25. The Trust completed comprehensive FRAMP care plans regularly throughout this admission. In line with NICE CG161, this noted Mr T was over 65 years old, had fallen in the last 12 months, was unsteady when walking and was confused/had a known cognitive impairment. These concluded he was a falls risk.

26. The records show the Trust put measures in place to manage Mr T’s falls risk, in line with NICE CG161.

27. The falls interventions noted throughout this admission were; orientation to the bed area, call bell within reach, frequently used items within reach, removed environmental clutter, bed placed near nurses station, appropriate footwear and a high-low bed (can be lowered whilst in bed to reduce harm sustained from any fall out of bed).

28. Despite these interventions, the records show Mr T fell on 13, 19 and 21 November 2023.

29. On 13 November, the records show Mr T had an unwitnessed fall in the afternoon and staff found him on the floor of his room. The records state he had no injuries.

30. In addition to the Trust’s falls policy, it also has an enhanced care policy which states there are several circumstances where patients may require additional supervision. One of which is where the patient is at risk of falling and this cannot be managed without supervision.

31. The records show the Trust initially assessed Mr T as not needing enhanced care. However, after his fall on 13 November, the records document nursing staff were closely supervising him as part of falls prevention. We think this therefore indicates Mr T required enhanced care.

32. The Trust’s policy on enhanced care sets out four different levels of observations, which staff should apply following a risk assessment score.

33. The risk assessment considers cognition, risk of falls, risk of absconding and clinical condition. The scores for each factor range from zero (no risk) to three (high risk). The scores are added together for a total score. The highest possible score is 12.

34. However, there are no records the Trust completed an enhanced care risk assessment.

35. Following Mr T’s fall on 13 November, his risk of falls would have scored a three. A score of three says ‘the patient is at risk of falling and is unable to understand the need to summon assistance to mobilise. The patient has a history of falling and is at high risk of harm as a result’.

36. Mr T would have likely scored one for cognition, as the records indicate he was confused but not agitated. He also would have likely scored one for risk of absconding, as he needed to remain on the ward for his safety but was not attempting to leave the ward. He would have likely scored one for clinical deterioration as the records indicate he was clinically stable with a low risk of deterioration.

37. Therefore, based on our review of the records, we consider Mr T would have scored a total of six overall on this risk assessment. For a total score of six the guideline says staff should conduct hourly observations as a minimum and the patient needs to be in an observable area.

38. The records do not show the Trust observed Mr T hourly or that he was in an observable area. This is not in line with the enhanced care policy.

39. On 19 November, the records show staff witnessed Mr T fall from sitting in a chair as he tried to stand up by himself. Staff noted Mr T did not suffer any injuries.

40. From the nursing advice, we understand it was appropriate for Mr T to be sitting out in a chair as staff were with him at the time to assist him. Unfortunately, it appears even with staff present, they could not prevent this fall.

41. On 21 November, the records show Mr T had an unwitnessed fall from his bed and was found lying on his face, with a head injury. The records at this time show bed rails were in use. We think it is likely Mr T attempted to get out of bed, climbed over the bed rails and fell.

42. The MHRA guidance discusses the use of bed rails and falls risk. This says bed rails should be used to prevent or reduce the risk of the person falling and suffering an injury. It says they are not intended to restrain people whose condition disposes them to erratic, violent or repetitive movement.

43. The guidance goes on to explain uses of bed rails in this way can increase the risk of falling as the patient may attempt to climb over the bed rail, leading to the potential fall from height. It says to prevent inappropriate or unintended restraint, there must be a robust assessment of whether the use of a bed rail will prevent the person from moving freely or make the person feel restricted from moving freely.

44. Based on the nursing advice we understand the Trust’s use of bed rails was not in line with MHRA guidance. This is because the records show Mr T had history of attempting to get up without assistance, was confused and mobile enough for them to cause harm either by entrapment or by him climbing over them and falling.

45. Considering the above, we find some aspects of the Trust’s falls prevention management followed NICE guidelines. However, we also consider the Trust did not follow its enhanced care policy, or MHRA guidelines when using bedrails. Therefore, we have found failings in the Trust’s falls prevention management for this time period. We consider the impact of this later in our report.

1 December 2023 to 3 January 2024

46. Similar to the above admission, the Trust conducted an initial FRAMP following Mr T’s transfer back to the hospital. This identified he was at risk of falls and noted interventions, like the ones in the above admission, to manage Mr T’s falls risk, in line with NICE CG161. The Trust completed these regularly throughout this admission.

47. On 2 December, the nursing assessments show Mr T required enhanced care due to his falls risk. As set out above, we consider Mr T would have required level two enhanced care, requiring hourly observations and placement in an observable area, in line with the Trust’s policy.

48. Despite recognising Mr T required enhanced care, the records do not show the Trust conducted an enhanced care risk assessment or put level two enhanced care in place.

49. On 6 December 2023 and 1 January 2024, the records show Mr T had an unwitnessed fall from his bed. The records show bed rails were in use at the time.

50. As explained above, the use of bedrails did not follow MHRA guidance as this increased Mr T’s risk of falling and harm.

51. On 8 December, the records show Mr T had an unwitnessed fall and staff found him sat on the floor. The records show he reported he got out of bed to use the toilet but he fell and hit his head on the sink. The nurse noted Mr T was not able to fully understand the risks of falling, injury or follow instructions to ask for assistance.

52. Shortly after this fall, the Trust assessed Mr T’s mental capacity and found he lacked capacity. The Trust put in place a deprivation of liberty safeguard (DOLs) for him. This meant staff could use a sensor mat for Mr T. Sensor mats are pressure sensitive and when stepped on they send an alert to staff to warn them a patient is moving.

53. Following this, the records show Mr T did not experience any further falls until 28 December. The records state this fall was unwitnessed, and staff found him lying in the corridor from being sat in a chair.

54. We can see some aspects of the Trust’s falls prevention management followed NICE guidelines and they used an additional intervention of a sensor mat during this admission. However, similar to the above admission, we can also see the Trust did not follow its enhanced care policy, or MHRA guidelines when using bedrails. Therefore, we have found failings in the Trust’s falls prevention management for this admission.

Impact

55. We have carefully considered the impact the failings, in the Trust’s falls prevention management, had on Mr T. We discussed this with our nursing adviser.

56. Ms K says the Trust’s failure to prevent falls put Mr T at higher risk of falls and injuries.

57. The RCOP national audit says ‘Tackling the problem of inpatient falls is challenging. There are no single or easily defined interventions which, when done on their own, are shown to reduce falls. However, research has shown that multiple interventions performed by the multidisciplinary team and tailored to the individual patient can reduce falls by 20–30%. These interventions are particularly important for patients with dementia or delirium, who are at high risk of falls in hospitals.’

58. In line with this and based on the nursing advice, we found the Trust’s use of bed rails and lack of enhanced care meant Mr T was at higher risk of falls and subsequent injuries.

59. This is because the use of bed rails meant Mr T, who was noted to be confused and mobile, would have to climb over the bed rails to get out of bed. The MHRA guidance says bed rails can increase the risk of falling as the patient may attempt to climb over the bed rail, leading to the potential fall from height. Falling from a height can increase the risk of injury.

60. Had the Trust put in place enhanced care, staff would have observed him hourly and placed him in an observable area. This could have opened up the opportunity for staff to assist Mr T when he was trying to get up.

61. We cannot say for certain had the Trust not used bed rails and put in place enhanced care observations this would have prevented Mr T from falling at all. This is because, sadly, even with intervention in place, falls can still happen. This is noted within the RCOP audit above.

62. Therefore, we find the failings we have seen, in the Trust’s falls prevention management, led to Mr T being at higher risk of falls and injuries. So, we find a missed opportunity to keep him at lower risk.

63. We also consider this caused Ms K significant distress. It is clear from our discussions with Ms K she was concerned about the Trust’s falls management.

64. Had the failings not occurred, we consider this would have made a difference to Ms K. This is because it would have given her the reassurance the Trust were doing everything possible to lower Mr T’s falls risk. The Trust not taking these steps means she continues to experience avoidable distress about what might have been different.

65. In the Trust’s response, it did not acknowledge anything went wrong in its falls management. However, it noted care around falls is discussed at its Harm’s Prevention Steering group where they look at good practice and share learning and ideas across the Trust in aim to reduce and prevent harm to patients.

66. Whilst this is positive to see the Trust learning from these events, we do not consider it addresses the specific failings and impact we have found. Therefore, we have made recommendations.

1. We have carefully investigated Ms K’s complaint about North Cumbria Integrated Care NHS Foundation Trust (the Trust). We were sorry to learn about her concerns and for the loss of Mr T. We recognise this has been a very upsetting time for her.

2. We have found failings in the Trust’s management of Mr T’s risk of falls. We found these failings put Mr T at higher risk of falls and injuries and caused Ms K distress.

3. Therefore, we uphold Ms K’s complaint. Our recommendations are set out at the end of this report.

67. We make recommendations in line with our Principles for Remedy which are reflected in the NHS Complaint Standards.

68. These say organisations should identify instances where things have gone wrong, take responsibility for these and find ways to put things right for those involved. They should learn from complaints to improve services.

69. We expect organisations to take action to compensate people appropriately if they cannot return them to the position they would have been in if the poor service had not occurred. In some cases, a financial remedy will be required. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale.

70. We have identified failings in relation to the Trust’s falls prevention management. We consider this led to Mr T being at higher risk of falls and injuries and therefore caused Ms K distress.

71. With that in mind, we recommend that following this final report the Trust:

• writes to Ms K to acknowledge the failings we have identified and apologise for the impact of the failings we have identified, within one month of this report • pays Ms K £500 in recognition of the failings in the Trust’s falls management causing Mr T to be at higher risk of falls and injuries, and distress, within three months of this report • explains what action it will take, or has taken, to address these failings within three months of this report - it should do this in the form of an action plan which should be shared with us, the complainant, Care Quality Commission (CQC) and NHS England too.

72. The Trust should send us evidence it has completed all of the recommendations we have made. We will check the action plan includes the reason for the failing (where possible), what the organisation does or will do differently in future, who is responsible for each action, the timescale for completion, and how it will be monitored.

73. This concludes our final report.