How a Falls Care Planning Expert Witness Assessed Three Unpreventable Inpatient Falls

When missing documentation complicates fall claims and care planning effectiveness

In this advisory review, an elderly patient experienced three separate falls during a hospital admission. The patient, who mobilised independently using a stick and was assessed by physiotherapy as low risk, fell: once from a wheelchair with the brakes off, once while walking to the bathroom using a bedside table instead of his stick, and once from bed during the night.

An Apex falls care planning expert witness was asked to consider whether any of these falls could have been prevented by a timely or more robust care plan. The expert concluded that while documentation and communication were poor, none of the events could have been avoided by care planning alone.

What the falls care planning expert witness found in policy and practice

The expert reviewed the local NHS policy, including the Inpatient Falls and Injury Screening and Management Procedure. Although electronic assessments (PICS) identified a risk of falling, the handwritten clinical record did not. No consistent care plan (FIRM or CEEP SAFE) was introduced from the start of admission.

Key observations:

• The first CEEP SAFE document was lost while the patient was in x-ray, with no record of when it was created

• The replacement form was implemented only after subsequent falls

• There was no clear record of whether a fall occurred during the early ward stay

• Nursing records failed to align with policy expectations around timely risk identification

• Physiotherapy assessed the patient as low risk several days after admission

“This was a patient with fluctuating mobility choices who occasionally ignored their stick, opted for furniture, and did not always engage with safer strategies. While care planning should have been in place, I cannot say it would have prevented any of the recorded falls.”— Apex Falls Care Planning Expert Witness

What a falls care planning expert witness expects in high-risk environments

Even when patients are mobile and deemed low risk, a robust care plan provides structure. An expert in falls care planning would expect:

1. A complete risk assessment within 6 hours of admission

2. Consistent use of either FIRM or CEEP SAFE pro forma, not both intermittently

3. Assessment of footwear, walking aids, and environment at point of entry

4. Nursing escalation when patients demonstrate unsafe substitute behaviours

5. Clear documentation of all post-fall assessments, even if injury-free

In this case, the care planning that did occur was reactive, not preventative. While risk factors were present, patient decision-making and equipment misuse were the leading contributors to injury.

When documentation gaps confuse causation

Throughout the review, the expert repeatedly returned to one core theme: without clarity on the timing or context of each fall, establishing causation becomes extremely difficult. The original fall location remains uncertain. While the patient’s stick was faulty, and footwear suboptimal, these were identified only after the fact, limiting the potential for early intervention.

The expert ultimately concluded that none of the three inpatient falls would have been avoided by earlier care planning alone. However, the absence of documentation, timely risk stratification, and proper care plan continuity complicated the Trust’s defence and left avoidable procedural questions unanswered.