How a Hospital Fall Prevention Expert Witness Reviewed Delayed Intervention After Bed Exit Attempts

Why multiple bed exit attempts should trigger a clinical escalation before the first fall

In this case review, a very elderly patient was admitted following a period of acute illness, confusion, and prior falls. Though recognised as frail and drowsy, she was initially managed with standard observation. Over the course of her admission, the patient repeatedly attempted to climb out of bed unassisted. These behaviours were recorded across multiple nursing notes yet no enhanced falls prevention strategy was initiated until after she suffered two unwitnessed falls in her room.

An Apex hospital fall prevention expert witness reviewed the timeline and concluded that a high-low bed, falls alarm, and visible nursing supervision should have been introduced days earlier. Had those interventions been put in place when warning signs first appeared, the falls were likely preventable.

What the hospital fall prevention expert witness found across care notes and handovers

The patient showed signs of declining cognition and increasing restlessness throughout her stay. Nursing documentation captured:

• Bed exit attempts logged over a two-week period, including repeated entries on consecutive days

• Confusion, visual hallucinations, and reduced oral intake

• Recurrent descriptions of the patient being found sitting on the edge of her bed or attempting to mobilise without assistance

• No high-low bed or enhanced supervision initiated until after both falls had occurred

• A lack of documented clinical handover regarding the need for enhanced monitoring during ward transfer

The falls themselves occurred within days of each other, and both caused head injuries yet neither incident prompted earlier intervention based on the documented behaviours in the preceding weeks.

“The opportunity to act was clear. This was not a sudden change in condition it was a steadily escalating risk profile that was never met with an appropriate response.”— Apex Hospital Fall Prevention Expert Witness

What a hospital fall prevention expert witness expects when patients show fall-seeking behaviours

When a patient repeatedly attempts to get out of bed, especially in the context of acute illness and confusion, standard nursing supervision is no longer sufficient. A fall prevention expert would expect:

1. Clear documentation of fall risk escalation after the first bed exit attempt

2. Clinical review and risk stratification if behaviours persist over multiple days

3. Introduction of high-low bed, sensor alarms, or cohorting in high-visibility bays

4. Verbal and/or written handover during ward transfer outlining fall risk and recommended supervision

5. Documentation of rationale for decisions not to implement escalation measures

In this case, standard interventions were delayed, and when they were finally applied, it was too late to prevent serious harm.

Missed escalation: when nursing vigilance is documented, but not actioned

The expert found that nursing staff were observant they regularly noted the patient’s behaviour and acknowledged the risk. However, these observations did not lead to action. A care plan was created, but not adapted in response to changing behaviours. There was also no evidence that the receiving ward was fully briefed on the fall risk during transfer.

The expert concluded that had a high-low bed, falls alarm, and visible supervision been initiated when the risk first escalated, the patient likely would not have fallen. A medical expert would be required to determine causation regarding her subsequent deterioration and death, but from a nursing perspective, the fall risk was not adequately managed.