A Clinical Risk Case Study- Failure to Implement Fall Prevention Measures

A Clinical Risk Case Study- Failure to Implement Fall Prevention Measures

Setting the Scene

During the Patients stay in hospital, the Patient sustained a fall, with no injury. The fall was not reported on the management reporting system. The following day the Patient had a further unwitnessed fall and sustained a life-threatening head injury.

The main learning points from this review stem from the following events:

  1. Upon admission into A&E, no multifactorial assessment was undertaken to identify the Patients risk factors to falling.

  2. The Patient’s falls and bedrail assessment failed to be fully completed or implemented, nor was it kept up to date when the Patient was transferred between wards, or when their condition worsened.

  3. Failing to report the initial fall on the management reporting system, therefore no changes were made to the Patients care plan to prevent a further fall from occurring.

  4. When the Patient had an unwitnessed fall, the trust did not provide an urgent CT scan.

Recommendations to Prevent Incident Recurrence and Improve Patient Safety

Falls in Hospitals are extremely common, especially amongst the elderly. However, these can be easily reduced if the trust has the appropriate measures in place to ensure prevention of falls.

TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:

1. Nursing staff need to ensure that a full Multifactorial Assessment is undertaken when an elderly Patient is admitted to A&E.

When an elderly Patient is admitted to A&E, who has reduced mobility and a history of falls, it is imperative that a multifactorial assessment is undertaken to ensure that their risk of falling during their stay in hospital is kept to a minimum. The multifactorial assessment may include (NICE, 2004);

  • Identification of falls history
  • Assessment of gait, balance and mobility, and muscle weakness
  • Assessment of osteoporosis risk
  • Assessment of the older persons perceived functional ability and fear relating to falling
  • Assessment of visual impairment
  • Assessment of cognitive impairment and neurological examination
  • Assessment of urinary incontinence
  • Assessment of home hazards
  • Cardiovascular examination and medication review

The purpose of undertaking this identifies the Patient’s individual risk factors for falling in hospital, enabling a care plan to be implemented to treat, improve or manage such factors during their stay in hospital.

2. Nursing staff must record all falls on the trusts risk management system

It is of vital importance that all falls are recorded on the Trust’s risk management system, this will allow clinicians to look at the root cause analysis of the fall and will assist them in making any appropriate changes to their care plan to ensure falls do not occur again.

3. Full, clear and concise fall and bed rails assessments must be completed and kept up to date when the Patient is moved to alternative ward, and when their condition worsens or improves.

When a falls and bed rail assessment is carried out, nursing staff must ensure that these are completed to an appropriate standard and are kept up to date when a Patient’s condition worsens or improves. This will allow the care plan to be changed in light of the Patients condition to ensure that the risk of falls is kept to a minimum.

4. Trusts must educate staff members on fall prevention

Education on falls prevention is imperative. Trusts must educate on a regular basis to ensure that all staff members are fully up to date with the steps and processes the trust have in place to reduce the risk of falls. Trusts must ensure that nursing staff are educated and trained on;

  • The trusts risk management system

  • The latest research and evidence-based practice

  • The specialist services that are readily available to help with fall prevention, such as specialist nurses and teams, occupational and physiotherapists.

  • Multifactorial assessment and the importance of completing in full a falls and bed rail assessment.

  • Post falls education - Staff must be able to educate the Patients and families on how to prevent further falls happening at home. Staff must be able to orientate with patients and promote good mobility habits such as; sleeping in a low-rise bed, wearing slippers, using walking aids and using call bells etc.

  • Trust must make every effort to locate and implement fall prevention equipment.

5. When beds and equipment are unavailable every effort should be made to locate them, and if still unsuccessful alternative methods should be implemented to prevent falls and ensure the safety of the Patient; such as providing crash mats and sensors.

Nursing staff should always place signs above the Patients bed to alert staff of any cognitive impairments, language barriers or special requirements and always refer to a dementia specialist if the Patient is suffering from this.

6. Urgent CT scans must be undertaken when a Patient has an unwitnessed fall.

If a Patient has had an unwitnessed fall a CT scan should always be considered, especially if they are known to be taking anticoagulation.

7. Trusts must monitor how effective the staffing levels are.

Trust’s must have effective and safe staffing levels, especially when nursing staff are looking after high-risk patients, for example 3 nurses to 20 patients of which a large majority are high risks to falls is simply not enough.

8. Trusts must ensure that ward layouts are as effective as possible.

Trust’s must ensure the layout of wards are as practical and sufficient as possible; such as placing more beds in-sight of the nursing station to ensure that high risk falls patients can be monitored more effectively. Trusts should ensure that high risk patients are moved to beds that are more easily accessible to the nursing staff to allow for better and more frequent observations. When this is not possible alternative methods must be implemented to counteract this, such as assessing the Patient hourly, instead of the 2 hourly rounding that is often put in place and, ensuring that the Patient has the most effective and appropriate fall prevention equipment such as such as low-level beds and crash mats.

To Summarise

It is of vital importance that trusts adopt and implement appropriate measures to reduce the risk of falls in hospitals that are leaving trusts venerable to litigation. Trusts must ensure that they are educating staff members on falls prevention whilst educating Patients themselves on what measures can be adopted at home to reduce the risk of further falls occurring.


  • Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group and Mrs Emily Ashworth B.Nurs (Hons) MRes NIHR ALP Hospital Nurse.. (2019). A Clinical Risk Case Study- Failure to implement fall prevention measures. TMLEP Clinical Risk Case Studies. 2 (4), 1.
  • https://www.nice.org.uk/guidance/cg161/chapter/1-Recommendations#preventing-falls-in-older-people-2

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0) 203 355 9796.