Case Study: When a Nursing Expert Witness Reviews a Disputed Hospital Fall

What happens when a patient alleges a fall but the records don't?

One Apex Nursing Expert Witness was instructed to examine a case of a patient who alleged he was dropped from a trolley to the floor following vascular surgery, it triggered a clinical negligence claim rooted in manual handling failure, poor communication, and missing documentation.

The NHS Trust denied the event ever occurred, and no incident form, nursing note, or surgical handover reflected a fall, so our Nurse Expert Witness was instructed to determine what had happened.

With no contemporaneous documentation, conflicting accounts, and gaps in risk reporting, the case hinged on whether the transfer was carried out in accordance with national patient movement protocols and whether breach of duty occurred if the fall did, in fact, take place.

Why manual handling allegations often hinge on documentation gaps

In the absence of CCTV, patient movement claims frequently rely on:

• Clear staff statements

• Detailed theatre and recovery notes

• Immediate post-event injury assessments

• Completion of a DATIX or incident form

• Prompt medical review and escalation

In this case, no incident report was filed, and no visual signs of bruising or injury were recorded in the ward notes the following day.

But the patient consistently reported being “dropped” during a slide sheet transfer from the surgical trolley to the ward bed and later underwent an x-ray for pain.

“Whether the fall happened or not is a matter for the Court. But if it did happen, the staff’s failure to report it and act on it represents a clear breach of duty.”— Apex Nursing Expert Witness

Key legal and clinical takeaways from a nursing expert witness

Even in the absence of proven causation, a qualified Nursing Expert Witness would assess any fall scenario for adherence to:

1. Local moving and handling policy

2. Appropriate staff numbers for transfers (minimum 3–4 for post-op patients)

3. Confirmation that brakes were applied and slide sheets used correctly

4. Safe use and condition of beds, trollies, or transfer equipment

5. Completion of documentation including:

   1. Incident forms

   2. Post-op handovers

   3. Wound checks and pain reviews

In this case, the expert advised that if the fall occurred as described, then failing to escalate or document it fell well below the standard expected of trained recovery and surgical staff.

When hospital records say nothing but the patient says otherwise

Hospitals have a legal duty to ensure safe movement and handling of patients at every stage of their care journey, especially after major vascular surgery - if this is not adhered to then they leave themselves open to the risk of clinical negligence claims.

This case illustrates that manual handling clinical negligence claims can emerge even in the absence of physical injury, when protocol is bypassed, and transparency is lacking.

Without a single reference to the alleged fall in the nursing, surgical, or discharge records, the credibility of both clinical documentation and the Claimant’s recollection may ultimately rest with the Court.

But from an Expert Witness standpoint, the record-keeping here fell short of what would be expected after a potentially serious event.