Serious 6 Patient fell from bed. risk assessment completed No obvious head on admission and falls prevention injury noted on plan in place; however, examination. Two management guidelines relating hours later patient to monitoring patients following a found to be fall were not followed resulting in unresponsive and a failure to detect the subsequently died. deteriorating patient. Referred to Coroner. Serious 6 Patient fell, sustaining Falls risk assessment completed a fractured arm. on admission and falls prevention plan in place.
Serious 6 Patient fell from bed. No obvious head injury noted on examination. Two hours later patient found to be unresponsive and subsequently died. Referred to Coroner. risk assessment completed on admission and falls prevention plan in place; however, management guidelines relating to monitoring patients following a fall were not followed resulting in a failure to detect the deteriorating patient. Serious 6 Patient fell, sustaining a fractured arm. Falls risk assessment completed on admission and falls prevention plan in place.
SSE-cases-2010-11-FINALv1.docx