Inpatient Falls Risk Assessment Failures: A Medico-Legal Case Study

An elderly patient admitted with suspected sepsis sustained a fractured hip following an unwitnessed fall during his hospital stay. Although a falls risk assessment had been completed, the case raised important questions about whether it had been sufficiently responsive to his changing clinical condition.

The patient initially presented with delirium - a well-recognised and significant risk factor for inpatient falls. Over several days, his cognition appeared to improve, and he was assessed as having capacity. He was mobilising with a Zimmer frame and was subsequently cared for in a high-visibility bay close to the nurses’ station.

Despite these measures, he was found on the floor in the early hours of the morning, having suffered a hip fracture requiring surgical intervention.

An Apex nursing expert witness was instructed to review the care provided, with particular focus on the adequacy of the falls risk assessment and associated care planning.

A dynamic risk that required a dynamic response

The key issue in this case was not whether a falls risk assessment had been completed - but whether it had been meaningfully updated to reflect the patient’s fluctuating presentation.

Early documentation clearly recorded confusion and delirium. However, as the patient’s condition appeared to improve, later entries suggested a return to baseline cognition. This apparent recovery may have led to an underestimation of the ongoing risk.

One critical factor stood out: the patient was documented as being unable to use his call buzzer. This should have triggered a more proactive supervision strategy, given his reliance on staff to request assistance.

Instead, the care plan did not fully reflect this increased dependency.

Similarly, while the patient was placed near the nurses’ station, this was relied upon as a protective measure in itself. In practice, proximity to staff does not equate to continuous observation - particularly in a busy ward environment.

The patient was not moved to an enhanced observation or cohorted bay, reportedly due to lack of availability, which further limited opportunities for closer supervision.

The reality of ward pressures

The expert recognised the broader context in which care was delivered. Staffing constraints, competing clinical demands, and limited access to enhanced observation beds all influenced decision-making.

At the time of the fall, nursing staff were attending to another acutely unwell patient within the same bay. The patient had been checked shortly beforehand and was noted to be resting.

This reflects a common challenge in inpatient care: balancing individual patient risk with the realities of finite resources.

As the Apex nursing expert noted:

“In an ideal setting, the patient would have been under constant observation. However, with the enhanced bay at capacity, placement near the nurses’ station represented the safest available option. There was no clear indication he would attempt to mobilise independently.”

Was the fall foreseeable?

Foreseeability was central to the expert’s opinion.

While the patient had recognised risk factors - including recent delirium and an inability to summon help - there was no documented history of him attempting to mobilise independently prior to the incident.

This absence of behavioural indicators made it difficult to conclude that the fall was clearly predictable.

The falls risk assessment itself had been completed by a qualified nurse and, in isolation, did not fall below an acceptable standard. However, its lack of specificity and limited reflection of evolving risks reduced its overall strength.

Documentation and defensibility - the falls risk assessment

The expert ultimately concluded that the care provided was defensible.

The nursing team acted in accordance with a standard accepted by a responsible body of practitioners, particularly when considered within the constraints of the clinical environment.

Crucially, this conclusion was supported by clear and contemporaneous documentation, which demonstrated:

• Ongoing assessment of the patient’s cognitive state

• Clinical reasoning behind bed placement near the nurses’ station

• Awareness of staffing pressures and competing priorities at the time

Although the outcome for the patient was serious, the fall itself was not considered clearly preventable on the balance of probabilities.

Key learning points

This case highlights several important considerations for clinical practice and medico-legal defensibility:

• Falls risk assessments must be dynamic and reflect fluctuating cognition

• Inability to use a call buzzer should trigger enhanced supervision planning

• Proximity to staff is not a substitute for active observation

• System limitations must be clearly documented when they influence care decisions

• Strong documentation remains critical in establishing defensibility, even in adverse outcomes