Case Study: How a Hospital Falls Policy Expert Witness Assessed Risk Stratification and Nursing Documentation Failures

A medically complex inpatient suffered three falls during a hospital stay. He was known to be independently mobile, though occasionally declined to use his walking aid. Nursing assessments on admission documented no previous falls and no initial indication that bed rails were needed.

However, inconsistencies between digital and paper-based risk assessments led to confusion about whether a formal care plan was ever completed. Meanwhile one fall, possibly the first, may never have been documented at all.

An Apex hospital falls policy expert witness was asked to review the records and assess whether nursing care fell below a defensible standard. The findings point to poor policy application, unclear handovers, and documentation practices that undermined the Trust’s ability to defend itself, even where harm may have been unpreventable.

What the hospital falls policy expert witness found in nursing notes and policy compliance

The expert found no contemporaneous documentation to confirm the patient’s first suspected fall on the initial ward. A policy-mandated risk management tool (FIRM) was triggered by the patient’s score, but no completed copy was found in the records. Later, after the patient was transferred to a new ward, three more falls occurred over a 48-hour period. These were unwitnessed, but occurred while the patient attempted to:

• Transfer to a wheelchair with brakes off

• Walk independently using a table instead of a stick

• Get out of bed, despite advice to call for assistance

  
  

Key issues highlighted included:

• Inconsistent documentation between PICS and nursing paper records

• A likely missed fall that was only reported retrospectively by the patient

• Delays in updating risk assessments and implementing bed safety precautions

• Hourly rounding carried out, but no clear care plan in place prior to final fall

• Miscommunication between wards and unclear handover entries

“Where a policy requires risk-based escalation, it must be followed in writing not just in good intent. The absence of the care plan itself became as damaging as any fall.”— Apex Hospital Falls Policy Expert Witness

What a hospital falls policy expert witness expects under national standards

For patients admitted with complex needs, even if initially mobile, a falls policy expert would expect:

1. Risk assessment within 6 hours of admission using standardised tools

2. A completed and filed care plan (e.g. FIRM or equivalent) for moderate-to-high-risk scores

3. Immediate escalation or reassessment after any suspected or reported fall

4. Properly countersigned handovers, especially during ward transfers

5. Clear entries justifying use or non-use of bed rails, low beds, or 1:1 supervision

In this case, the documentation reflected mixed perceptions of the patient’s risk level, with PICS triggering a plan but none located. Without a consistent paper trail, the Trust was left exposed, despite staff appearing to act with reasonable vigilance.

When policy isn’t followed, even preventable harm becomes harder to refute

The expert ultimately found that two of the three documented falls were likely unpreventable caused by patient decisions and not nursing neglect. However, the failure to document a suspected earlier fall, combined with the absence of the required care plan, made it harder to rule out nursing error in the final fall.

The expert noted that policy inconsistencies and documentation gaps were the greatest liability not necessarily the care itself.