Case studies

Elderly patient put at greater risk of falling through healthcare assistant's inadequate training

We were instructed to investigate an upsetting case involving an elderly and vulnerable patient. The lady concerned, who suffered from dementia, was admitted to hospital with severe dehydration.

A manual handling and falls risk assessment identified her as being at high risk of falls due to various factors, including her tendency to get up unassisted, her memory problems which meant that she was unable to recall the need to summon assistance and her extreme physical frailty. The assessment concluded that she required one-to-one nursing support, often termed 'specialing'. 

Despite the assessment and the hospital falls policy (based on NICE guidelines), the patient was left unattended by a healthcare assistant who had been assigned to take care of her. When the assistant returned, she was found lying on the ground with a fractured hip, amongst other injuries. She subsequently developed septicaemia. 

The hospital involved conducted a serious incident investigation, which identified that the healthcare assistant had not received adequate training regarding the safeguards required for patients at high risk of falls. There was a failure to provide sensor mats that would have alerted staff if the patient began to move and she should not have been left unattended.

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