14 February 2023

NHS Highland fined over death of pensioner who fell from hospital bed

14 February 2023

A Scottish NHS board has been fined £180,000 over the death of a 78-year-old man who fell from his hospital bed three times.

NHS Highland was fined on Tuesday after admitting a breach of health and safety regulations at Inverness Sheriff Court on January 31.

The prosecution service told the court that Colin Lloyd was admitted to Raigmore Hospital on February 6 2019, after a fall at home.

He was assessed as unsuitable for bed rails but was at “high risk” of falling and required one-to-one care and observation.

The tragic death of Colin Lloyd could have been prevented had suitable and sufficient measures been put in place

The room Mr Lloyd was transferred to was managed by a staff nurse who was looking after two rooms of six beds and assisting in triage in another room, meaning he did not receive the one-to-one care needed.

During his time in hospital, he fell from the bed three times.

The first fall, on February 6, was discovered after a witness heard a scream from Mr Lloyd’s room.

He had a cut to his forehead and a CT scan found a brain bleed.

The second fall happened six days later and a third fall two days after that.

This final fall reopened the head wound and Mr Lloyd suffered further bleeding in the brain.

His condition worsened and he died on the ward two days later.

During Mr Lloyd’s time in hospital, the Crown Office said the court heard staff repeatedly made requests for more nurses to help provide the care he needed as there were new admissions to care for and other patients with enhanced care needs.

The prosecutor said, at the time, there was no apparent overall view of staffing requests across wards or formal system in place to escalate unfilled staffing requests or to review the situation to look for alternative solutions.

Speaking after sentencing, Debbie Carroll, of the Crown Office and Procurator Fiscal Service, said: “The tragic death of Colin Lloyd could have been prevented had suitable and sufficient measures been put in place.

“Highland Health Board failed to have effective arrangements and control measures in place to prevent or mitigate falls to patients identified as being at risk and, as a result, Colin Lloyd suffered fatal head trauma.

“This prosecution should remind duty holders that a failure to manage and implement effective measures can have fatal consequences and they will be held accountable for this failure.”

NHS Highland has apologised for the failures made during Mr Lloyd’s care.

Fiona Hogg, director of people and culture, said: “We are deeply sorry for the failures identified in our care that led to the death of a patient at Raigmore Hospital in 2019.

“We recognise the lasting hurt this will have caused to those who loved and cared for Mr Lloyd and we are sorry for letting them down. Our internal review following the incident identified several areas of improvement and, as a result, we have made a number of changes to our systems and practice.

“This includes clearer, more responsive processes for escalating staff shortages, the introduction of volunteers to provide additional support and companionship for older people in the acute hospital setting, and enhanced training for staff caring for people who are at risk of falling.”

Health and Safety Executive (HSE) inspector Penny Falconer said: “This incident could so easily have been avoided by simply carrying out correct control measures and safe working practices.

“Organisations should be aware that HSE will not hesitate to take appropriate enforcement action against those that fall below the required standards.”

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