When Missed Checks Lead to Missed Chances: A Case of Neurological Observation Failure

Why timely neuro checks matter more than ever in post-fall protocols

A patient recovering in a cardiology unit appeared clinically stable and was assessed as safe to mobilise independently with a Zimmer frame. Yet following a bathroom fall, unwitnessed and understated, the absence of timely neurological monitoring after the incident would set off a rapid and ultimately fatal decline. This case highlights how a simple omission of post-fall neurological observations, despite clear policies in place, can contribute to avoidable patient deterioration and serious medico-legal consequences.

While clinical documentation noted the patient as "neurologically intact" shortly after the fall, no formal pupil checks or repeated Glasgow Coma Scale (GCS) assessments were conducted in line with the Trust’s own Falls Care Bundle protocol. When the patient was found unresponsive several hours later, it was too late and neurological damage had advanced undetected.

This is a textbook case of neurological observation failure, where the absence of structured and documented neuro obs led to a missed opportunity to detect and act on clinical deterioration in time.

The impact of missed post-fall neurological observation failure

A serious incident report later confirmed that required observations quarter-hourly for the first hour, then hourly, then four-hourly which were never completed. Notably, despite a retrospective entry from the nurse describing the fall, key neurological indicators such as pupil response and consciousness levels were undocumented. No formal neuro observation chart was commenced.

This lack of escalation and failure to follow protocol amounted to a clear breach of nursing duty. The expert nursing opinion determined that while the fall itself could be considered accidental, the absence of protocol-driven neuro checks following the fall meant an early warning opportunity was missed.

“This Trust uses a good system, a falls sticker is placed in the hospital records which sets out what should happen and the frequency of the observations post-fall… Despite this, the prescribed policy was not followed and the frequency of neuro observations was lacking.” — Apex Nursing Expert Witness

Recognising neurological risk after a fall in high-dependency units

The patient had been previously assessed as safe for discharge and was mobilising with supervision. But night-time staffing limitations and the misjudged reassurance from a brief doctor’s review led to a blind spot. While the cardiology registrar did note the patient as neurologically intact, there was no management plan documented, and staff were not prompted to initiate neurological observation protocols.

From a nursing perspective, the fall’s circumstances, including its unwitnessed nature and mechanism (a “thud” in a closed bathroom), warranted structured neurological observation regardless of a doctor's initial informal review.

Key lessons for clinical governance teams and legal professionals

This case underscores the importance of embedding compliance with post-fall neurological observation protocols into clinical culture not just paperwork. For solicitors handling medico-legal claims, it highlights:

1. The evidential weight of omitted protocol-driven actions.

2. The role of structured observation in building or breaking the causation link.

3. The importance of staff understanding observation timing and triggers, not just documentation.

Nursing experts can clarify whether clinical reasoning and documentation meet national and local care standards, especially in cases where deterioration occurs out-of-hours or in low-visibility settings.

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