Case Study: How a Commode Fall Expert Witness Reviewed Post-Operative Fall Risk and Missed Bedside Supervision
- Apex Experts
- Oct 21
- 2 min read
When post-surgical patients are left unsupervised at the commode, predictable harm follows
In this complex inpatient case, an elderly patient recovering from a right knee replacement was left unattended on a commode. Although she had not yet mobilised post-operatively, and physiotherapy had recently documented that she lacked independent sitting balance, she was left alone while a nurse sourced a new mattress. Moments later, another staff member found the patient on the floor, having suffered a fall with facial and soft tissue injuries.
An Apex commode fall expert witness was asked to review the care standards. The expert concluded that supervision should never have been withdrawn in these circumstances and that the fall was foreseeable and avoidable had national nursing standards been followed.
What the commode fall expert witness identified as key breaches in fall risk planning
The expert reviewed the care plan, physio assessments, medication records, and nursing documentation. Key concerns included:
The patient had not been hoisted or supported to a seated position since surgery
A physiotherapist noted the patient lacked sitting balance and recommended hoisting support
There was no recorded communication of this advice to nursing staff
The patient’s antihypertensive medication had been withheld just before the fall due to low blood pressure
Staff allowed the patient to position herself on the commode and left the room
A loose commode arm was identified after the fall, but timing was uncertain
The patient had recently received an enema, further increasing fall risk
“Where a post-op patient hasn’t yet been mobilised, has known hypotension, and is recovering from major surgery, they should not be left alone even if they insist. This is a duty of care, not a negotiation.”— Apex Commode Fall Expert Witness
What a commode fall expert witness expects in post-operative and high-risk toileting care
When patients are post-op and have known fall or balance risks, a commode fall expert witness would expect:
Staff presence at the bedside until the patient is safely back in bed
Written care plan adjustments if new risks are identified by physiotherapists
Documentation of how a patient was seated on a commode, particularly if self-repositioning occurred
Formal reassessment of supervision needs after each toileting episode
Explanation of why a patient was left unattended, if this deviates from expected care
In this case, none of these measures were clearly documented or enacted. The expert noted that while the patient may have verbally requested privacy, this should not override clinical judgement in high-risk scenarios.
Device-related injury confusion added further complexity
The patient also later alleged a catheter bag had rested on her leg for several days, causing a burn. However, the expert could not confirm this from the records and found no clear evidence of a device-related wound. Nonetheless, the expert highlighted that a separate split to the patient’s sacrum, documented on return from theatre, may have been an unreported area of concern and merited further investigation.
Ultimately, the expert concluded that the primary and clearest breach was leaving a patient with known hypotension, poor balance, and post-op fatigue alone on a commode. The fall likely would have been avoided with bedside presence or high-low bed use.