Case Study: How an Inpatient Falls Expert Witness Reviewed Four Unprevented Falls in a Rehabilitation Setting

Why repeated falls without revised care planning can turn risk into liability

In this detailed case review, an elderly patient was transferred to a rehabilitation hospital following a period of acute inpatient care. Despite being flagged as a falls risk from admission, the patient experienced four separate falls over a fortnight, the last of which contributed to a rapid decline and subsequent death.

An Apex inpatient falls expert witness was asked to assess the nursing risk assessments, care planning, and supervision procedures in place. While the hospital's falls policy was praised for its clarity, the expert found critical failings in its practical application, particularly around risk reassessment and enhanced supervision.

What the inpatient falls expert witness found in care plans, rounding, and supervision

The patient had multiple comorbidities, limited mobility, and demonstrated confusion from early in his stay. Despite this, after each fall, the falls care plan and risk assessments were not promptly reviewed and enhanced safety interventions, such as fall sensors or cohorting, were not introduced in a timely way.

Key nursing failings identified included:

• No documented review of falls care plan immediately after the first three falls

• Confusion and unsafe mobility were noted, yet standard 1-hourly rounds continued

• Absence of fall sensors despite recurrent unassisted movements

• Lack of clarity around whether a call bell was consistently accessible or used

• Disjointed record-keeping across digital and paper systems

• Delayed escalation following a decline in GCS after the final fall

“Falls management is not just about policy, it’s about consistent escalation. After the second fall, this patient needed constant supervision or a change of environment. That didn’t happen.” — Apex Inpatient Falls Expert Witness

What an inpatient falls expert witness expects after repeated inpatient falls

Best practice following inpatient falls, particularly in rehab settings, requires:

1. Immediate risk reassessment and care plan review after every fall

2. Introduction of fall sensors or cohorting after more than one incident

3. Detailed documentation specifying which fall mitigation actions were implemented

4. Clear visibility on supervision levels and rationale for staffing decisions

5. Medical and nursing handover that includes full risk profiles and behaviour trends

In this case, despite the presence of a good policy, the implementation of those standards was inconsistent. The care plan template listed appropriate interventions but was not individualised, leaving ambiguity about what was actually being done.

Four falls, one outcome: the gap between policy and prevention

The final fall, which occurred while the patient attempted to walk unassisted, led to bruising, reduced GCS, and a deterioration requiring transfer to an acute hospital. While the death was attributed to a natural cause, the impact of the fall was identified as a contributing factor.

The expert concluded that from the second fall onward, the patient’s needs exceeded what the rehab unit could safely provide without enhanced supervision. A failure to escalate supervision or transfer the patient contributed to further risk and ultimately poor outcomes.