When a Falls Prevention Expert Identifies Systemic Failures in Care Planning

Why A Falls Prevention Expert Believes Short-Term Admissions Still Demand Full Falls Risk Protocols

Short-stay or respite care should never mean shortcuts in clinical planning. Yet, in this case, a frail 78-year-old woman with dementia suffered six separate falls across five respite admissions. Each incident was either poorly documented, not escalated, or entirely unaddressed. The final fall, out of bed during the night, led to a fractured neck of femur and her subsequent death.

Despite her high-risk profile, the facility treated each new admission as a blank slate:

• No care plans were initiated during the first three admissions

• Staff recorded her walking unsafely without assistive devices but took no action

• Crash mats, bed sensors, and enhanced supervision were never implemented

• Family were not informed of most incidents

• Risk scores were calculated but not followed up with intervention

  
  

The Falls Assessment That Wasn’t Enough

From a falls prevention expert perspective, documentation was sporadic, risk assessment tools were inconsistently applied, and incident forms were often missing entirely. Although staff noted the patient’s wandering behaviours, nothing in the care record suggested meaningful prevention was attempted.

“The Claimant's care record reads like a series of missed warnings, each fall was a missed opportunity to prevent the next.”— Apex Falls Prevention Expert Witness

Even after suffering a fall with head trauma, there was no increase in supervision or reassessment of her environment. In her final stay, she was found on the floor in the early hours, having rolled from a low bed without a crash mat.

Consequences of Poor Record Keeping and Delayed Safeguarding

Following her injury and hospitalisation, the woman was deemed medically fit for discharge after several weeks. However, she deteriorated quickly and died not long after. The safeguarding investigation found that staff had failed to provide reasonable fall protection and that post-fall management was substandard. Key consequences included:

1. Partial substantiation of safeguarding failings

2. Missed reporting obligations to the family

3. Failure to involve external tissue viability or dementia specialists

4. Inadequate adherence to CQC Regulation 12 (safe care and treatment)

5. Legal exposure due to a pattern, not a single error of neglect

   
   

Lessons from a Falls Prevention Expert

This case reinforces that falls prevention is not about reacting, it’s about planning. A qualified falls prevention expert would expect the following in any high-risk patient’s care plan:

• Daily reassessment of risk factors (e.g. cognitive impairment, medications, night-time agitation)

• Use of fall mitigation tools: crash mats, low-low beds, perimeter alarms

• Multidisciplinary input for high-risk individuals (GP, OT, TVN)

• Family engagement and timely incident reporting

• Documentation of rationale when safety equipment is declined (e.g. “trip hazard” concerns must be clinically justified)

Respite care patients deserve the same level of planning and protection as long-term residents, especially when their risk is well known.

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