Serious 6 Patient fell and Patient fell whilst standing from project completed and new risk assessments Completed. sustained commode. and education in place for staff. fractured shoulder. Patient later died from unrelated events. Serious 6 Patient fell and Patient was not compliant with medical Medical team to discuss with Mental Health team as Completed. fractured ankle. treatment, due to other medical to future management of patient in ways that will Agreed plans in conditions. allow required medical management. place for ongoing care. Serious 6 Patient fell and Unpreventable fall. Review identified No recommendations. fractured hip that all appropriate actions pre and post requiring surgical fall were taken. repair. Serious 6 Patient fell Inadequate care planning and Falls project completed and new risk assessments mobilising and management of specific needs of a and education in place for staff. fractured confused elderly patient with physical shoulder. No limitations and other medical problems surgical in an unfamiliar environment of a intervention hospital. required. Serious 6 Patient fell and Patient with confusion mobilised and fell. Falls project completed and new risk assessments Completed. fractured hip. and education in place for staff. Surgical repair required. Serious 6 Patient fell and Patient with limited mobility mobilised project completed and new risk assessments Completed. required surgical and fell. and education in place for staff. repair of lacerations sustained in fall.
Serious 6 Patient fell and sustained fractured shoulder. Patient later died from unrelated events. Patient fell whilst standing from commode. project completed and new risk assessments and education in place for staff. Completed. Serious 6 Patient fell and fractured ankle. Patient was not compliant with medical treatment, due to other medical conditions. Medical team to discuss with Mental Health team as to future management of patient in ways that will allow required medical management. Completed. Agreed plans in place for ongoing care. Serious 6 Patient fell and fractured hip requiring surgical repair. Unpreventable fall. Review identified that all appropriate actions pre and post fall were taken. No recommendations. Serious 6 Patient fell mobilising and fractured shoulder. No surgical intervention required. Inadequate care planning and management of specific needs of a confused elderly patient with physical limitations and other medical problems in an unfamiliar environment of a hospital. Falls project completed and new risk assessments and education in place for staff. Serious 6 Patient fell and fractured hip. Surgical repair required. Patient with confusion mobilised and fell. Falls project completed and new risk assessments and education in place for staff. Completed. Serious 6 Patient fell and required surgical repair of lacerations sustained in fall. Patient with limited mobility mobilised and fell. project completed and new risk assessments and education in place for staff. Completed.
SSE-cases-2010-11-FINALv1.docx