When a Hospital Falls Expert Witness Identifies Systemic Failures in Supervision and Risk Assessment

How a hospital falls expert witness evaluates observation gaps and post-fall response

An elderly and acutely unwell patient, admitted with pneumonia and confusion, was left unsupervised in a hospital bay overnight. He fell from his bed, sustained a head injury, and later died in hospital. His clinical picture was marked by agitation, dehydration, and visible delirium which was clear to multiple staff members, yet records show a consistent failure to act upon risk indicators.

An Apex hospital falls expert witness was instructed to review the standard of nursing care. The conclusion was stark: delayed risk assessments, inadequate 1:1 supervision, and poor fluid, pressure, and delirium care all amounted to avoidable harm.

Why early intervention and escalation protocols were absent

From admission, the patient showed signs of deteriorating cognition and escalating infection. The records revealed:

• A 48-hour delay in carrying out a formal falls risk assessment

• Underscoring of risk level, placing the patient in a lower-risk category

• Misuse of bed rails, despite visible restlessness and mobility attempts

• Inconsistent care planning, with 1:1 nursing removed without clinical justification

• Lack of escalation to senior nursing staff, even when agitation worsened

“He was agitated, pulling at cot sides, rocking from side to side, classic signs of unsafe behaviour. He was left alone when he needed continuous supervision. This was not unforeseeable, it was neglect.”— Apex Hospital Falls Expert Witness

What a hospital falls expert witness expects from high-risk care

When a patient is clearly high risk, elderly, delirious, and septic a hospital falls expert witness would expect:

1. Completion of a falls risk assessment within 6 hours of admission

2. Escalation to senior staff if a patient becomes acutely agitated

3. Clinical justification when choosing not to use 1:1 supervision

4. A documented care plan reflecting behaviour patterns and nursing interventions

5. Documentation of fluid balance, pressure relief, and mental state monitoring

This patient was placed in a “high activity” bay but left unattended while nurses responded to another patient’s chest pain. During this time, he climbed from bed and fell.

Documentation shortfalls, confusion over Haloperidol, and missed 1:1 support

The expert was particularly critical of:

• The absence of a coordinated plan for delirium management

• Confusion over whether Haloperidol could be administered, despite a prior dose having helped

• Long gaps in pressure relief records

• 23-hour periods without urine output being noted

• No escalation to the duty nurse manager for additional staff, despite increasing supervision needs

This incident was entirely avoidable. With appropriate nursing judgement and hospital adherence to policy, the patient’s fall and subsequent injury would likely not have occurred.