Falls in Hospital

[FlipFlopVibe]

I may have posted in the wrong place...

Can anyone advise on the correct procedure and questions we should be asking regarding a fall in an NHS hospital?

My DGM is 94 and fell on her stairs last week and broke her hip. She had a hip replacement the next day and was recovering well. My DM went to visit her today and she was totally out of it and couldn't wake her up. My DM on leaving asked the nurses about it and it turns out she fell getting out of bed during the night, hit her head and needed a CT scan. This came back clear.

No one informed my DM about the fall and we would be non the wiser had she not mentioned it. On visiting again tonight my DGM is still not conscious which the nurse said is not good and she needs to be awake more by tomorrow. Although the initial scan was clear there can be a delay in any bleed showing.

I think their care has been substandard, the guard rails on the bed can't have been on otherwise she couldn't have got out. She is very vulnerable due to age/strong painkillers and they should have taken more care to ensure her safety. What questions do we ask of the hospital to ensure this isn't just passed off?

I don't think bedrails have been used for quite a few years to be honest as they present their own risks.

I'm honestly not sure why you think that your grandmother falling out of bed means that her care has been substandard. It was an accident. What do you think they should have done but didn't?

Was your grandmother in her own home when she had the initial fall where she broke her hip?

They should have informed her NOk (your mum?) and should also have a bed rail assessment which is reviewed daily. Unfortunately it isn’t always possible to prevent falls… Post operative delirium isn’t uncommon sadly and this may have contributed to a fall, and as a 96 year old she is particularly at risk of this. It’s not a blame game.

They’ve definitely used bed rails over the last few times my parents/husband have had long stays in hospital.

And i don’t understand why someone would think an elderly person falling out of bed is acceptable care. It happened to my father too. In his case the physios left him in a chair and the nurses didn’t check him. Both groups were at fault. They did ring me though. The trouble is the nurses are run ragged, understaffed and, from what I’ve seen (my above mentioned relatives have clocked up 24 weeks in hospital over the last 18 months), those that are quiet often get left while nurses are tied up with the shouty patients.

I’m sorry to hear your DGM is so poorly. You must be really worried about her.

Bed rails are even more of a hazard as patients try to climb out over them and then suffer more significant injuries. Unfortunately the NHS is so short staffing wise that it is not always noticed that someone is trying to get out of bed. Perhaps what caused her initial fall has resulted in her falling again. Poor communication is again a symptom of overstretched staff rather than a desire to keep it from relatives. 💐💐

Bed rails won't be used if the patient is at risk of trying to climb over them or if they have capacity and refuse them.

If your mother is next of kin she should have been informed.

Falls aren't necessarily due to neglect, they can't all be prevented.

I used to work on the ward. Our policy was to inform first contact (NOK) as early as possible..so say 7.30am after handover if they fell in the night. Bed rails can be seen as entrapment and a patient has far higher risk of hurting themselves climbing over them than falling without them. We did get slipper socks with grips for high risk patients, so if they got up independently there was grip under their feet. Not all falls are preventable..but I would ask to see the falls policy for the trust (probably online), question why your Mum wasn’t told and ask how often your Grandmother was monitored. We had a policy of checking half hourly for suspected head injury. She may need 1:2 supervision..although extra staff are like goldust these days. I hope she’s better soon.

Oh, never mind all that. This is a really tough time for all of you and it’s a common grief-displacement strategy to get all irate, thinking about who you can blame and/or sue, but it’s neither healthy nor helpful. Look after yourself, and those around you.

The bed rails have been up on both sides and on the end of the bed the whole time she has been in. There has been no explanation as to how it might have happened, they didn't even tell us until it was brought up why she had gone downhill so fast.

I understand that at 94 most would assume she's end of life and that's what happens to elderly people but she hasn't been to the doctors for over 20 years, she takes no medication at all. When she tripped up the stairs last week and broke her hip, she stood up went into the kitchen, got her mobile phone and text (yes she texts at 94) my DM to ask her to cancel her hair appointment. It's a new world for us to suddenly see her unconscious and contemplating a seeious injury when she was doing so well in her recovery.

From what I have seen online, hospitals should be taking falls in their care seriously. The below is a document from Brighton and Sussex Hospital that I found online (this is NOT the hospital DGM is in). It seems there is a very stringent protocol however each hospital seems to have different procedures and I can't find anything for the hospital she is in so I wondered who we should approach.

www.bsuh.nhs.uk/library/wp-content/uploads/sites/8/2020/09/C003-Prevention-of-Inpatient-Falls.pdf

Bed rails should not be used, they can be more dangerous. A patient who is not fully aware will often try to get out of bed. The fall is usually when they try to stand and their legs won’t hold them up so it’s more of a collapse than a fall. Where a bed guard / rails are in place, they will try to get over the guard / rail and have an actual fall causing much more damage.

That document is dated 2015. Practice has changed since then.

You can speak to the ward manager, and if you're not satisfied, contact PALS.

However, do consider that falls can't be completely avoided in any setting. There should be a bed rails risk assessment.

She should have been wearing slippers or grippy socks, but tbh if she's just had a hip replacement my question would be why did she fall?

~Was she wearing slippers or slipper socks?
~Was she trying to reach for a frame?
~Had she called for assistance? If so, was there a delay in attending to her?
~Was anyone with her when she fell?

The staff member allocated to care for her should have completed a DATIX form or similar incident form. That should give more information.

http://www.cntw.nhs.uk/wp-content/uploads/2020/07/POL-001-047-Safe_and_Effective_Use_of_Bedrails.pdf
This is slightly more up to date.

Thank you that's really helpful!

Yes it's old and the wrong hospital, my point is should every hospital have something like this and if so who can supply a copy

She will have had a falls risk assessment done when first admitted and this should be updated to reflect the fact she has actually fallen so is clearly high risk. The updated risk assessment should list what measures are being taken to prevent further falls.

As a pp said a Datix should have been completed to record the incident, it's like a (very) mini investigation into adverse events and accidents.

Unfortunately I think you'll need to just keep on at the staff and be very present and engaged with them to make sure you know what's happening with her care. Keep asking questions and providing support in whatever ways you can.

Good luck and I hope she is on the mend soon. This sounds very stressful for you all.

If the bed rails were on she could well have fallen as a result of climbing over them.

I think I'd want to set up a meeting with the senior charge nurse to get more information.

Falls happen in hospital. Sometimes it is sadly inevitable but the chance of it happen should be minimised and when it does happen the harm should be minimised. She should have had a bedrail risk assessment which should have been updated if there was a change in cognition or mobility. There should have been a falls risk assessment and a care plan in place put interventions in place to reduce risk (slipper socks, mobility aid to hand, family aware of inc falls risk, blood pressure checked when she mobilises to see if it drops when she stands, does she have her glasses in with her? Etc.). When there is a fall there is a safety incident report completed at the time which will be reviewed by management to review the circumstances and if it was an avoidable event and what learning can be put in place from this event.

To me it is completely wrong that a fall with harm that family weren't contacted overnight. If she had been fine and settled back in bed I would have called in the morning but as she is not responsive you should been told, definitely not only told when visiting. If it was my gran I'd want to know the exact circumstances, were the bedrails insitu and she slid to the end of the bed(most common)? Did she fall over the bedrails (less likely with her age and recent hip replacement but not impossible)? How long was she on the floor and has she been alert/responsive since?

Went through similar with my grandad. He had so many falls. At home, hospital, care home. Broke so many of his bones over his final few years, some multiple times. Hip, knee, cheekbone, jaw, wrist, fingers, ribs.

Pretty much all his own fault. He had a walker but refused to use it because it was 'faff'. Refused to press the call button if he wanted to get up because 'he could manage'. Literally would try climb over guard rails. Short of chaining him to the bed with handcuffs and having motion sensors on him there was nothing anyone could do. He wouldn't help himself, and would not accept that loss of independence.

It is possible the hospital got it wrong. But if she is someone that hasn't gone to the doctors in 20 years and still thinks she's perfectly fine, its very possible she just tried to get up because she didn't want to bother the nurses thinking she was capable of doing it herself.

As PP
I'll also say ask for a geriatrician assessment. The orthopaedic surgeons are great at fixing fractures in people not great at investigating the reason why you GM fell. She may have had a heart attack, a stroke or mini stroke (TIA) or she tripped over. She may have had a long lie after the fall, she may have been sick with a cold for a week before.
The reason I mention all of these factors is you add an anaesthetic to this and pain and pain killers and you GM is at risk of delirium.

Delirium can be hyperactive, hypoactive or mixed. Delirium is a horrible complication and increases the risk of falls. What reduces the risk of delirium and the risk of falls is more skilled staff.

Your DM is completely within her rights to complain as the nurses should have called her after she fell or asked the day shift to call. I have gone through my nurses for a shortcut for not calling about a fall or a pressure injury.
Ring the ward and ask for an appointment with the nurse manager. Talk to this person. Ask about what falls prevention strategies were in place and post fall, was hourly rounding being done? Did she have a catheter because in a person with a delirium they cannot understand that the sensation is just the catheter ballon and think they need the bathroom. Was she wearing TEDS? They are leathal for slipping.

If she is not satisfied with the answer then she can complain. I don't know the NHS terminology for that service.

Bed rails are a blessing and a curse. I have had to fish a 40kg 90yr lady out from between the rail and the mattress in a soaking wet bed so couldn't even get on the bed from the other side but also seen them be useful with a person who was used to sleeping cross wise in a bed....

I hope your GM recovers

In Australia, use of bed rails is considered unlawful restraint. If patients are a known falls risk they have an alarm pad on either side of the bed. If your DGM had developed a fever (UTI/Chest infection, anything) it is very common for them to become restless and not know what they are doing. I’m sorry your poor DGM hurt herself. I hope she wakes up.

The bed rails may be an issue they are up on both sides and the bottom. She has never been in hospital since she last gave birth in 1959 and may have forgotten where she was in the middle of the night. She still has a catheter in and doesn't need to get up. In 10 days she has only been out of bed once and does know she can't stand without nurses and a physio to assist. My DGM is now awake but doesn't want to try leaving the bed at all now as she's had such a fright.

Unfortunately this evening our confidence in her care has reduced even further, my DM found a Deprivation of Liberty form in her folder which states she has no one who can act in her best interests on her behalf and that she is at risk of neglect should she return home. My DM is retired and perfectly capable of caring for and acting in her best interests. She has POA as do my DS and I should my DM not be able to. My DM has already arranged for a stair lift to be fitted at home and a new HSL chair so DGM can stand up confidently. DM is worn out visiting the hospital twice a day, every day so to say no one is acting in her best interests and is at risk of neglect is incredibly hurtful.

Who filled out the DoLS form? If nurses think that DoLS is in place (and DoLS criteria are very strict) then that explains why no one was contacted-potentially they think that contacting home is a safeguarding risk. Do you yourself know much about DoLs? This helps explain a bit more. https://www.ageuk.org.uk/globalassets/age-uk/documents/factsheets/fs62deprivationnoflibertyysafeguards_fcs.pdf

The form was filled out by someone from the council, it was completed at 2044hrs the evening she fell. My DM had only left the hospital at 1930hrs so in that short space of time she had the fall, the council worker attended, did the full assessment and reviewed all the information and established there was no one to act in her best interests. It quite clearly states that POA should be consulted.

Surely you’re speaking about dementia patients or something?? My father, mother and husband all had rails, it was even written onto the chart on the wall. None of them had dementia. They all used the rails to help themselves sit up etc while they were weak.