Sentinel 6 Inpatient fall sustaining a Review completed. A family member Clear guidelines are to be developed to assist broken hip. The patient later who was visiting the patient raised the staff discuss and clarify the involvement of died. bed and left the bedside without family when visiting, and the need to notify notifying ward staff enabling the patient staff of departure. unobserved to climb out of bed, fall to the floor and fracture his neck of femur. Falls risk assessments must be carried out for all patients on admission and where While known high falls risk, no formal appropriate during the course of the admission. assessment of same documented in file. Sentinel 11 Patient with known epilepsy Review completed not a clinical – was found dead while awaiting incident. Died of natural causes. discharge. [Information provided after publication of SSE report, so this incident is included in the overall data.]
Sentinel 6 Inpatient fall sustaining a broken hip. The patient later died. Review completed. A family member who was visiting the patient raised the bed and left the bedside without notifying ward staff enabling the patient unobserved to climb out of bed, fall to the floor and fracture his neck of femur. While known high falls risk, no formal assessment of same documented in file. Clear guidelines are to be developed to assist staff discuss and clarify the involvement of family when visiting, and the need to notify staff of departure. Falls risk assessments must be carried out for all patients on admission and where appropriate during the course of the admission. Sentinel 11 Patient with known epilepsy was found dead while awaiting discharge. Review completed – not a clinical incident. Died of natural causes. [Information provided after publication of SSE report, so this incident is included in the overall data.]