How a Falls Management Expert Witness Reviewed Inpatient Supervision and Missed Escalation

A preventable fall, a fractured hip, and missed opportunities

An elderly patient recovering from thoracic surgery suffered two inpatient falls within 24 hours, the second of which resulted in a fractured hip. Despite being known to be confused, high-risk, and recently assigned enhanced supervision, the patient was left alone and unsupervised at night. The hospital later acknowledged staffing gaps but did not explain why 1:1 care was not maintained or escalated.

An Apex falls management expert witness was instructed to assess whether hospital staff met the expected standard of care. The report identified a series of concerning failings: missed observations, inadequate response to deterioration, and poor documentation.

When signs of deterioration are missed and supervision fails

In the hours leading up to the fall:

• Nursing staff recorded increasing confusion and agitation

• The patient’s blood pressure dropped to a critical level (60/46) without evidence of escalation

• Urinary retention contributed to repeated attempts to get out of bed

• A healthcare support worker was previously allocated, but not present during the incident

• No safety plan was updated following the first fall

“This was not an unpredictable fall. The risk was well established. When a vulnerable, confused patient is left unsupervised, the system has already failed.”— Apex Falls Management Expert Witness

What a falls management expert witness expects in complex care scenarios

In any inpatient setting where a patient is known to be high-risk, a falls management expert witness evaluates whether:

1. Risk assessments are updated following a fall

2. Supervision decisions are documented and clinically justified

3. A safety plan is implemented and reviewed regularly

4. Escalation occurs when observations deteriorate (e.g. low BP)

5. Enhanced care protocols (like bay tagging or 1:1 support) are actively maintained

In this case, documentation was inconsistent, and decisions about withdrawing supervision were not explained. The patient’s second fall, leading to serious injury, was both foreseeable and likely preventable.

Why falls prevention is about action, not just risk scoring

Identifying risk is not enough. Without acting on that knowledge by ensuring supervision, documenting care decisions, and escalating concerns patients remain unprotected.

The expert concluded that:

• Supervision was insufficient given the patient’s known state

• Deterioration was not clinically escalated

• The second fall likely would not have occurred if enhanced care had continued as planned

These findings highlight how even short lapses in care coordination can have lasting consequences.