Kenneth Swift

Regulation 28: REPORT TO PREVENT FUTURE DEATHS —
reference KENNETH JOHN SWIFT

This report summarises the findings from an investigation into concerns raised
by HM Coroner under regulation 28, and the actions taken to minimise future
risk and harm.

Matters of concern:

1. Although assessed as being at risk of falls and despite being
positioned in a bay that was close to the Nurses’ Station in the Ward
for better observation, Mr Swift was also recommended to have a falls
sensor as he was observed by the Occupational Therapist and
Physiotherapist trying to mobilise without supervision despite advice
not to do so.

2. It was said in evidence that:
No falls sensor was immediately available — Mr Swift was put on a
‘waiting list’ of 34 existing patients needing such equipment. The cost
of chair sensor was said to be £60; of a bed sensor £90. The hospital
was said to be in a tendering process to acquire such equipment. In the
relevant Ward (AMU/AMB) 95% of the usual 30 patients (when full) at
any one time would have been assessed at risk of falls.
Four sensors have been acquired since Mr Swift's death for use at the
present time in that Ward.

3. Such a mechanism may have made staff aware that Mr Swift, an
elderly man known to be capable of confusion and already suffering
from infection that could be aggravated by immobility if injured, was
mobilising unsupervised.

4. That in this Ward at least there is the potential for future deaths
resulting from, or the aggravation of, conditions by the consequences
of falls in other patients.

Introduction/background:

Falls and falls related injuries are a common and serious problem for patients
in hospital, particularly older patients. People aged 65 and older have an
increased risk of falling and in the hospital setting, they are particularly
vulnerable due to acute illness, chronic illness and the associated frailty and
anxiety.

York Teaching Hospital NHS Foundation Trust has a policy which provides
guidance to reduce the risk of patients falling in hospital. This policy provides
a consistent approach to preventing falls in hospital, based on best practice
and clinical evidence of effectiveness.

Some patients may continue to fall and incur harm even when best practice is
followed. In such cases we try to ensure vigilant monitoring, re-assessment

and where necessary, modifications to the plan of care and actions to
minimise the risk of harm.

All adult in-patients aged 65 and over should have a falls risk assessment
completed within six hours of being admitted to hospital. People under 65
years of age who are judged by a clinician to be at higher risk of falling due to
an underlying condition should also have the assessment completed. The
assessment process will generate a list of preventative measures to be
considered by staff completing the assessment. Preventative measures may
include: provision of walking aids, review of night sedation, sight and hearing
checks, provision of a low profile bed, non-slip footwear or sensor alarms.

The use of bed and chair sensors will not stop someone from falling but they
should be considered where patients are unable to use a call bell and need
assistance to mobilise. The sensors should be used as a mechanism to alert
staff that a patient might be getting out of bed or standing from a chair, but
they should only be used as a tool to help reduce the risk of someone falling
and in association with close observation. They cannot be used in isolation
and should be part of a package of interventions. Constant alarms on bed
sensors can be very irritating for the patient and therefore they may not be
suitable for confused patients. In the case of patients who are confused or
who fail to follow advice the sensors may not be beneficial and a position on
the ward which facilitates frequent observation by nursing staff may be more
beneficial.

Response to matters of concern:

We have a multi-factorial electronic assessment tool which is used by the
nursing staff to determine risk of falling and which preventative
measures/interventions should be used to prevent or minimise the risk of
falling and injury. The tool triggers recommendations based on individual
risks.

The Physiotherapist on Ward AMB requested a falls sensor for Mr Swift and
was unable to secure one. She reported to Sister on Ward AMB that the
Medical Equipment Library had advised her that there was a waiting list of 34
patients for sensors. It is correct that at the time of the request there was nota
sensor available for Mr Swift however our investigations with the Medical
Equipment Library have failed to identify any occasion where more than five
patients were awaiting a sensor at any one time and therefore we are unable
to substantiate the information provided at the inquest.

Since 2014 we have purchased 55 falls sensors, including 10 in August 2016
but due to malfunction and lost parts we only had 30 sensors available across
the Trust at the time of Mr Swift's assessment. Since August 2017 we have
purchased an additional 30 complete sensor kits at a cost of £650 per kit and
we are reviewing the demand and will purchase additional kits if necessary.

It is possible that the use of a falls sensor may have alerted staff more quickly
to the fact that Mr Swift was mobilising unsupervised. However the evidence

in the literature (National Institute for Health and Care Excellence 2013)
reports that the use of bed and bedside falls sensors as part of a single
intervention does not reduce falls rates.

Our approach to preventing harm from falls follows the NICE guidelines
(2013) which recommend that, for patients at risk of falling in hospital, a multi-
factorial assessment and multi-factorial interventions should be considered
and this did happen in Mr Swift’s case.

Mr Swift was assessed as being at risk of falling whilst he was in hospital and

to minimise the risk the following preventative measures were put in place:
e Footwear assessed for suitability

Walking aids provided

Bed provided near the toilet and nurses station

ECG checked

Blood glucose checked

Referral made to physiotherapist and occupational therapist

Lying and standing blood pressure checked

Medications reviewed

Condition of spectacles checked

Plan to supervise the patient when walking to the toilet.

Following investigation into the circumstances of Mr Swift's fall and serious
injury we have taken the following actions:
a. implemented process of escalation to Matron/ Patient Safety
Team when sensor requests cannot be achieved
b. agreed new management system with the Equipment Library for
the storage and supply of fall sensors to the clinical areas
c. introduced additional training for all staff including the
Equipment Library Staff on the correct use of fall sensors
d. implemented process for auditing the use of sensors
e. implemented process for ensuring on going supply of sensors
due to the short warranty of the pads
f. implemented tendering process to ensure value for money and
efficiency of product
g. further promoting the use of multi-factorial interventions to
reduce falls incidents and harm.

Evaluation of the actions above will be reported to the Falls Steering Group in
December 2017.

Reference:

Falls (2013) NICE guideline CG161.

Deputy Director of Patient Safety

September 2017.