Case Study: When Visibility Decisions Increase Patient Fall Risk

In hospital care, side rooms are often seen as a practical solution - providing privacy, infection control, and a calmer environment. But for confused or high-risk patients, these rooms can also create unseen danger. A recent case reviewed by an independent hospital falls expert witness illustrates how a seemingly routine decision led to a preventable, life-changing injury.

The Background

The patient, an elderly woman with a recent history of stroke, was admitted to hospital with infection-related confusion and frailty. From the moment of admission, she was assessed as high risk of falls.

Despite this, within days she was transferred to a side room - a space with limited visibility from the main nursing station. The decision was reportedly made to reduce infection risk due to loose stool, though no microbiological evidence supported the need for isolation.

Once placed in that room, her visibility to staff sharply decreased. Observation notes were incomplete, risk assessments inconsistent, and supervision levels did not reflect her vulnerability.

Within a week, she was found on the floor with a severe head injury that later required transfer to a neurosurgical unit.

The Expert’s Instruction

A falls prevention and hospital safety expert witness was instructed to determine whether the fall and resulting cerebral injury — could have been avoided with appropriate risk management.

Their review focused on three questions:

1. Was isolation clinically justified?

2. Were falls risk assessments conducted accurately and acted upon?

3. Were national standards for observation, hydration, and supervision met?

Findings: A Pattern of Omission

The expert’s findings were stark. Despite multiple completed falls assessments, several were partially filled or incorrectly scored. None reflected the patient’s known confusion, recent infarct, or reduced mobility.

Several key issues emerged:

• Inappropriate side-room allocation: A high-risk, cognitively impaired patient was placed in a low-visibility area without additional supervision.

• Inconsistent documentation: Behaviour charts, mobility notes, and hydration records were incomplete, leaving no clear picture of risk escalation.

• Lack of multifactorial falls assessment: NICE guidance (CG161, now superseded by NG249) was not followed.

• Hydration neglect: Fluid intake fell to zero in the 48 hours before the fall, likely contributing to hypotension and dizziness.

• Medication oversight: Blood pressure-lowering drugs were administered without review despite worsening frailty.

• No compensatory measures: No falls alarm, bed sensor, or increased nurse observation was recorded.

The expert concluded that the fall was foreseeable and preventable.

Expert Commentary

“Side rooms are not neutral spaces,” the expert explained. “They reduce visibility and staff contact. When used for high-risk patients, isolation must be clinically justified, documented, and paired with strong mitigation measures such as increased rounding or sensor alarms.”

This quote underscores a broader truth: while infection control and patient privacy are valid priorities, visibility remains central to safety.

Missed Opportunities for Prevention of Patient Fall Risk

The investigation found several opportunities where better documentation, planning, or communication could have altered the outcome.

1. Clinical Justification

There was no microbiological reason for isolation. A cohorting strategy — placing the patient in a visible bay with infection precautions — would have maintained supervision while managing infection risk.

2. Supervision Protocols

Nursing plans noted “assist with one,” but failed to specify when or how staff should support mobility. Without a structured observation plan, responsibility was left ambiguous.

3. Hydration and Medication Review

Poor oral intake and continued antihypertensive use contributed to postural hypotension, increasing falls risk. Earlier hydration intervention could have stabilised her condition.

4. Environmental Design

Side rooms are inherently higher-risk for confused patients. Good practice requires either enhanced monitoring technology or dedicated staff oversight to offset the visibility gap.

The Legal and Clinical Analysis

From a medico-legal perspective, this case highlights the intersection of visibility management, documentation, and duty of care.

The expert applied recognised principles of clinical negligence — considering breach of duty and causation:

• The decision to isolate lacked justification or senior review, falling below expected professional standards.

• The absence of monitoring or mitigation created foreseeable risk.

• The fall and resulting head injury were directly attributable to this lapse.

In short, the harm was avoidable.

Lessons for Practice

This case offers valuable learning points for hospitals, clinicians, and medico-legal professionals:

1. Visibility is a safety factor.Isolation can unintentionally remove patients from regular supervision. Every decision to use a side room for a confused or frail patient must be weighed against the increased risk of falls.

2. Documentation protects both patients and staff.Incomplete or inaccurate falls assessments weaken both care and legal defensibility. Risk scores must be updated and acted upon.

3. Hydration and medication reviews prevent harm.Dehydration, combined with hypotensive medication, creates predictable instability.

4. Side rooms require compensatory monitoring.Where visibility is low, technology (alarms, sensors) and observation schedules should be heightened.

5. Leadership oversight is essential.Senior clinicians should review all side-room allocations for patients with falls risk or cognitive impairment.

Broader Implications for Expert Witnesses

For expert witnesses, this case demonstrates the need for multifactorial review — not just of clinical care, but of systems, documentation, and environment.

When analysing similar incidents, experts should consider:

• Whether falls risk assessments were completed accurately and reviewed daily.

• If the physical layout of the ward or staffing model increased foreseeable risk.

• Whether decisions were made for convenience, infection control, or patient safety.

Causation opinions should address whether enhanced visibility or supervision would likely have prevented harm.

Conclusion

This case study illustrates how a well-intentioned decision — isolating a frail, confused patient for infection concerns — became a critical patient safety failure. The fall that followed was not the result of one mistake, but of multiple missed opportunities: incomplete documentation, poor visibility, and absent supervision.

The lesson is clear: in high-risk care environments, every decision must be clinically justified, documented, and monitored for safety impact.

At Apex Experts, our panel includes clinicians specialising in falls prevention, frailty care, and hospital risk management. We provide independent, CPR Part 35-compliant expert witness reports that help legal teams and healthcare providers understand where systems fail — and how harm could have been prevented.