Unpreventable vs. Unacceptable: Navigating the Clinical Standards of Hospital Falls

In the high-pressure environment of an acute hospital ward, the prevention of inpatient falls remains one of the most significant challenges for nursing staff and hospital management alike. For solicitors, insurers, and medico-legal professionals, these cases often present a complex and emotive question: is a fall a sign of a lapse in care, or is it an inherent risk of patient care that cannot always be mitigated?

At Apex Experts, our panel is frequently called upon to provide expert testimony that clarifies the boundary between a "calculated risk" and "clinical negligence." Understanding the national standards - specifically those outlined by the National Institute for Health and Care Excellence (NICE) and the Royal College of Nursing - is essential for determining whether the standard of care was met in any given instance.

The Myth of Universal Prevention

A common starting point in many legal claims is the assumption that because a patient was identified as a "high fall risk," any subsequent fall must be the result of a failure in supervision or equipment. However, nursing practice in the United Kingdom is guided by the principle of "reasonable care," not "absolute prevention."

The healthcare system operates within a framework that balances safety with the preservation of a patient’s dignity and independence. To remove all risk of falling, one would essentially have to restrain a patient - an act that is not only unethical but often illegal under the Mental Capacity Act 2005. Therefore, in the eyes of a nursing expert witness, a fall is not prima facie evidence of negligence. Instead, the focus must sharpen on the robustness of the risk assessment and the suitability of the measures put in place to manage that risk.

The Foundation of Defensible Care: Assessment and Planning

When an inpatient fall expert witness reviews a claim, they look for a "gold thread" of documentation that begins the moment the patient is admitted to the ward. To meet a reasonable standard of care, several layers of assessment must be evident in the medical records.

1. The Initial Multifactorial Risk Assessment

   
   

Following guidelines such as NICE CG161, clinicians must assess much more than just a patient’s age or their history of falls.

A comprehensive assessment must consider:

• Cognitive State: Is the patient suffering from delirium, dementia, or acute confusion?

• Continence Needs: A significant number of falls occur when patients attempt to reach the bathroom unassisted.

• Medication Review: Are they on diuretics (increasing the need to mobilise) or sedatives (increasing instability)?

• Environmental Factors: Is the lighting adequate? Is the patient wearing "grip" socks or sensible footwear?

2. Dynamic Re-assessment: The Moving Target

A risk assessment is not a static document to be filed away. It must be a "living" part of the patient’s care. Standard practice dictates that assessments should be updated following any major change in the patient’s condition, a change in medication, or most importantly, following a "near miss." If a patient is found sitting on the edge of their bed when they should be resting, the nursing staff must document this and escalate the intervention plan accordingly.

Proactive Measures vs. Restrictive Practice

One of the most delicate balances in nursing is managing safety while respecting patient autonomy. Expert witnesses frequently evaluate the use of physical and environmental aids to see if they were used appropriately or if they inadvertently contributed to the risk.

Bed Rails (Cot Sides) and the Risk of Escalation

While often seen by families as a safety feature, bed rails can occasionally increase the risk of injury. A confused patient may attempt to climb over the rails, leading to a fall from a greater height. An expert will look for a specific Bed Rail Risk Assessment. If rails were used without an assessment of the patient’s cognitive ability to understand their purpose, this could be flagged as a breach of duty. Conversely, if a patient has the capacity to request them for a sense of security, that choice must be respected.

The Role of the Nurse Call System

The proximity and accessibility of the nurse call bell are vital. If a patient is cognitively able to use the bell but it was placed out of reach, this is a clear and defensible breach of duty. However, for a patient with advanced dementia who cannot grasp the function of a call bell, providing one is not a sufficient safety measure. In those instances, an expert would look for alternative strategies, such as the use of pressure-sensitive floor mats or "sensor beams" that alert staff the moment a patient leaves their bed.

Supervision, Staffing, and the "Cohort" Model

In many modern wards, high-risk patients are "cohorted" in bays where they are visible from the nursing station or a central point. This is often referred to as "bay tagging" or "enhanced supervision."

A nursing expert witness will scrutinise the staffing levels against national standards and local trust policies. However, even with "safe" staffing, a nurse cannot be in two places at once. If a nurse is in a bay attending to a highly complex task - such as assisting a patient with a respiratory emergency - and a patient in the next bed falls, the law generally views this as a tragic but non-negligent event. The standard is "reasonable supervision," not a one-to-one permanent guard, unless the patient's specific risk level (such as extreme agitation) demanded it.

The Reality of "Unwitnessed" Hospital Falls

Many inpatient falls occur in the early morning hours (between 02:00 and 06:00) or during periods of clinical handover. If a fall is unwitnessed, the expert witness examines the Intentional Rounding logs.

Standard practice involves staff checking on high-risk patients at set intervals (usually every hour) to address the "4 Ps": Pain, Position, Personal needs (toileting), and Placement of items (call bell/water). If a fall occurs within minutes of a documented check, and the patient has no prior history of impulsive attempts to mobilise without help, the expert may conclude that the fall was unpredictable and unpreventable.

Post-Fall Management: The Second Half of the Duty

The duty of care does not end when a patient is found on the floor. In many clinical negligence claims, the breach isn't the fall itself, but the failure to manage the aftermath correctly. An expert witness expects to see a rigorous post-fall protocol, including:

• Immediate Neurological Observations: Especially critical if the fall was unwitnessed or if the patient is on anticoagulants (blood thinners), where a head strike could lead to an internal bleed.

• Medical Review: A prompt assessment by a member of the medical team to check for hip fractures or internal trauma before the patient is moved using a hoist.

• Incident Reporting and RCA: The hospital should conduct a Root Cause Analysis (RCA). If the hospital's own internal investigation identifies a failing - such as a broken sensor mat, this becomes a vital piece of evidence for the solicitor.

The Expert’s Conclusion: Distinguishing Negligence from Adverse Outcomes

Ultimately, the role of an Apex expert is to provide a "human" and "educational" perspective on the realities of the ward. We must distinguish between a lapse in practice (such as a failure to implement a specific falls care plan) and an adverse outcome that occurred despite good care.

In the case of a patient with liver failure and confusion, their physical instability is a medical fact. If the nursing staff assessed that risk, provided a call bell, conducted regular rounding, and responded promptly when the fall occurred, the standard of care has likely been met. The law acknowledges that hospitals are not risk-free environments.

For solicitors, the key is to look beyond the injury and scrutinise the documentation thread. Was the patient’s risk understood? Was the care plan active and tailored? And was the response to the fall immediate and thorough? When these standards are met, we can conclude that the healthcare team did everything "reasonably" possible to protect their patient, even when the outcome was unfortunate.