Falls Care Plan Negligence: When Policy Is Ignored, Patients Pay the Price

What happens when a high-risk patient is placed in isolation without a falls care plan?

In the world of hospital risk management, few failures are as avoidable, or as damaging, as the omission of a falls care plan for vulnerable patients. In this case review, a senior nursing expert examined a tragic and preventable fall that occurred after a high-risk patient was moved to a side room without supervision, assessment, or an individualised care strategy.

The patient was already assessed as high risk for falls. Despite this, no falls care plan was documented, no clear mobility assessment occurred, and no nursing observations were adapted after the patient was moved into a side room, isolated and out of view.

Falls care plan negligence in policy and practice

According to the hospital’s own Falls Prevention and Management Policy, high-risk patients must receive “optimum observation” and should be placed in a cohort bay, never left entirely unattended. Yet in this case, the patient was moved into a private side room a decision that contradicted every procedural safeguard in place.

Despite suffering from loose stool, being catheterised, and requiring frequent nursing assistance, she was placed in an environment where quick access to care was unlikely. This left her at risk of attempting to mobilise independently and unsafely, exactly what the falls care plan was designed to prevent.

“Placing a high-risk patient alone in a side room without a care plan or enhanced supervision directly contradicts the trust’s own policy on falls prevention.”— Apex Nursing Expert Witness

Absence of care planning is a breach, not an oversight

The absence of a falls care plan was not a documentation error, it was a breach of nursing duty. A robust plan would have identified the risks, recommended a cohort bay placement, and ensured staff were aware of the specific steps needed to keep the patient safe. When challenged legally, the defence claimed that falls are not always preventable. While true in general, this argument weakens significantly when basic safeguards were never in place.

In the expert’s opinion:

• There was no documentation of care planning or risk mitigation

• No rounding or visibility tools were implemented

• Nursing supervision was not adapted despite the room change

• The patient fell while alone, without any preventive strategy evident

Why visibility and rounding matter in fall prevention

Falls care plan negligence is often tied to visibility. Side rooms reduce the chance of staff noticing a patient attempting to stand or reach for assistance. This is particularly dangerous when the patient is physically compromised or confused.

In this case:

1. A cohort bay was not used, despite policy direction

2. Observation requirements were not fulfilled

3. Staff did not adjust care despite the change in location

4. The patient fell alone in her room

This event was not a random accident. It was the foreseeable outcome of ignoring best practice.

Need a nursing expert witness to comment on a falls case? Get in contact with us at info@apexexperts.co.uk, give us a call on 0203 633 2213 or visit our contact us page.