Gerald Cruse

RUH Cohort 
Falls Report 
Re 

JANUARY  12 

Bristol Ambulance EMS 
Authored by: Clinical Safety Team 

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 Executive Summary 
This is a	 report on	 the fall that occurred	 in	 Royal United	 Hospital (RUH)	 Ambulance 
Cohort Area (ACA): 

This report is after the incident has been	 heard	 in	 coroners court. Therefore, it focuses 
on	 how we can	 learn	 from this event to	 ensure it does not happen	 again. It primarily 
consists	 of	 an evaluation of	 the	 current	 clinical	 guidelines	 and practices, and how we 
may be able to implement changes to improve our practice as a company. 

Summary: 
Following the Joint	Royal	College 	Ambulance 	Liaison 	Committee 	(JRCALC) Guidelines, 
specifically, ‘Falls	 and Trauma	 in the	 Older Adult’ and ‘Frailty’ are	 inadequate	 to 
prevent	a 	similar	fall	from 	occurring 	again in 	an 	ambulance 	cohort	area.	The 	falls 	risk 
assessment within these	 guidelines	 focuses	 on an in-depth	 holistic approach, with	 the 
aim of identifying	 patient specific mobility needs. It is	 not designed to highlight 
patients at immediate risk of falls in	 a hospital department. Therefore, for Bristol 
Ambulance, to help prevent	 further	 similar	 incidents, should consider several possible	 
interventions, 	including: 

• Adopting a	 falls risk assessment protocol similar to RUH’s 	(Page 6).	 This	 rules	 
patient in	 or out of a ‘Falls Risk’ Category, and	 highlights patients with	 colored 
blankets. 

• Ensure commodes are available for patients who	 are at falls risk	 to limit	 their	 

need	 to	 mobilise. 

• Conduct a joint falls risk assessment with 	the 	Trust	we 	provide 	cohorting 	for.	 

This should	 be done as part of the set-up	 process to	 ensure shared	 
understanding of how to	 best highlight and	 manage at-risk 	patients. 
• Before staff begin	 work within	 a	 cohorting area	 they conduct company 

mandated training 	specific	to 	falls 	risk	and 	management. 

For a detailed	 evaluation	 and	 implementation	 of the above please see below. 

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 JRCALC Guidelines: 
JRCALC Guidelines appear inadequate to assess falls risk in hospital.  Below is an evaluation of the 
guidelines	 as they pertain to this incident. Excerpts are on page five. 

Falls	 and	 Trauma	 in	 the Older	 Adult Guidelines: 

•  The Scope of this Policy is for assessing patients who have fallen. This guideline is implicitly for 

pre-hospital falls. It	 emphasises two key areas: Major Trauma	 and Long lie. 

•  This	guideline does not	 include a	 risk of falls assessment	 for in-hospital patients. The 

emphasis of the falls assessment	 is a	 holistic ‘multi-factoral’ approach - there is no threshold 
for who is a	 high, medium and low falls	of	risk. 

•  The guidelines indicate that	 it	 is down to the paramedics professional opinion, and that	 their 
opinion should be informed by risk factors and pertinent	 history such as section 4.4 and 
Appendix B	 below. 

•  Section 14.4 specifically highlights a	 mobility assessment, but	 this is well beyond the scope of 
ACA as it	 involves observing “postural stability, gait, stride length and sway” with the aim of 
identifying “slow tentative pace, loss of balance, short	 strides, shuffling, en-bloc turning, and 
inappropriate mobility use”. This would not	 be feasible in ACA due to volume of patients and 
work load of the clinician. 

•  Appendix B highlights an “informal assessment” of mobility in Functional, Mobility and 

Assessment. 

•  There are no guidelines for a	 practical and timely falls risk assessment	 in the context	 of ACA 

within JRCALCs ‘Falls and Trauma	 in the Older Adult’. 

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 JRCALC Guidelines	 Excerpts: 

4.4	 Table	1	 - Examples	 of Intrinsic and Extrinsic Risk	 Factors 
Intrinsic Risk	 Factors 
Effects of ageing: 
Muscle weakness, Frailty, Urological conditions Gait & 
balance problems, Poor vision	 and	 hearing, A	 fear of 
falling 

Extrinsic Factors 
Lack	 of handrails and grab bars, 
Poor stair design 
Poor lighting 	or 	glare 
Obstacles, clutter &	 trip hazards 
Slippery or uneven 

Acute and	 chronic conditions: Arthritis Stroke 
Incontinence 	Dementia 	Parkinson's 	disease 
Musculoskeletal disease or previous injury, Sensory 
deficits Diabetes Postural hypotension	 Depression 

Medications: Side	 effects (e.g. sedation or slowed 
reaction times)	 Drug interactions New or	 recently 
adjusted medications 

Appendix B: Falls	 Assessment Checklist 
Falls History 
Cardiovascular 

Neurological 

Functional, Mobility and 
Gait Assessments 

GI/GU 

Sensory Distrubance 

Muscoskeletal 

As per section 5 of Guidelines 
Consider cardiac arrhythmias, TLoC and postural hypotension (NB: postural hypotension 
may be affected by drugs, disease or age-related deterioration of	 autonomic nervous 
system) – see section 6 
Consider delirium – refer	 to the Confusion Assessment	 Method within the 
SWASFT Frailty	 clinical guideline (section 4) 
Record	 an	 informal assessment of mobility – see section 14.	 Consider footwear and	 
availability and appropriateness of mobility aids. Assess frailty and consider referral for 
a	 Comprehensive	 Geriatric Assessment – refer	 to the SWASFT Frailty clinical guideline 
(section 2)Is the patient	 able to undertake basic Activities of	 Daily Living 
(ADLs)?:Personal hygiene e.g. bathing, grooming, maintaining continence Dressing 
Eating Transferring/mobility 
Assess alcohol intake – see section 9Consider nutritional intake and dehydration. Assess	 
urgency or frequency of urination	 and	 any symptoms indicative of a urinary tract 
infection.	Nocturia 	may 	be 	linked 	to 	sleep 	disturbance, 	poor lighting, not using mobility 
aids or disorientation 
Ask if the patient noted	 loss of vision	 or increase glare from lights, particularly at night. 
Enquire whether an eye test has recently been undertaken and if glasses are worn or 
requiredAsk if	 the patient	 has noticed diminished hearing, requires hearing aids and if	 
they are working adequately. Consider	 if	 a hearing test	 may be required 
Undertake a c-spine assessment – see section 3. Assess	 for signs	 of head injury – see 
section 10 and NICE Head Injury guidance. Assess joints and muscles for pain, swelling	 
and deformity; both acute	 and gradual onset. Consider low muscle	 mass and 
sarcopenia. Undertake a skin assessment for pressure ulcers	 and high risk areas	 – refer	 
to	 SWASFT Pressure Ulcers clinical guideline 

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 Frailty Guidelines: 

•  The Frailty Guidelines do not	 have a	 defined Scope. They provide reference material, 

assessment	 aides and clinical management	 recommendations. 

•  No specific falls risk assessment is included in the JRCALC Frailty guidelines.	 

•  The core message is assessing a	 patient	 compared to their normal base line. Assessment	 is 
focused on the injuries from the fall and long lie effects, and use of the Rockwood Frailty 
Score.	 

•  The 	guidelines	 overlap considerably with ‘Falls and Trauma	 in Older Adults’ 

•  Functional Assessment	 in Section 5. Table 5.7 details the FRESH	 model, but	 it	 is essentially 
another holistic history gathering tool but	 is specific to frailty and activities of daily living.	 

•  There are no guidelines for a	 practical and timely falls risk assessment	 in the context	 of ACA 

within JRCALCs ‘Frailty Guidelines. 

Ambulance	 Hospital Handovers Guidelines: 

•  Within ‘Ambulance Hospital Handovers’ guideline Appendix 7 details the remit	 of cohorting. 
The guideline primarily focuses on when a	 cohorting area	 would be created due to surges in 
demand and how this would be decided and staffed. 

• 

It	 does not	 appear to directly apply to a	 permanent	 cohorting area, however, the RUH	 ACA 
appears to meet	 the standards of this guideline when it	 comes to the responsibility and 
actions of BA staff e.g regular observations, assisting with personal care and escalating 
deteriorating patients. A falls risk assessment	 is not	 detailed anywhere in the guidelines. 

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 Hospital Falls Risk	 Assessment 

Summary: 
This is the ED Falls Risk Assessment. The tool is based on the clinician asking questions of the patient	 
based on several elements of the NICE guidelines. This appears to work on the basis that	 if the 
patient	 hits just	 one of the ‘holistic’ risk factors, they are considered at	 risk and are highlighted with a	 
yellow blanket	 and yellow socks. This Risk Assessment	 appears to be quite a sensitive tool, to 
highlight	 any patient	 at	 risk, no matter how small. It	 is	 worth noting on reflection that	 the triage 

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 nurse who took the handover omitted this risk assessment. It	 is unclear if this was an oversight	 or on 
purpose. If this was completed this would have helped to highlight	 the patient	 who fell. 
NICE	Guidelines: 

The NICE Guidelines CG-161 ‘Falls in Older People: Assessment	 and Prevention’ were last	 updated 
after a	 ‘Surveillance’ period in 2019. This guideline does include guidance for falls in hospital. 

.	 

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 Summary: 
NICE Guidelines recommend a	 multifactorial assessment	 for risk of falls. They specifically do not	 
recommend ‘Fall Risk Prediction Tools’ such as the Morse Fall Scale or St.Thomas Risk Assessment	 
Tool for Falling in the Elderly (STRATIFY) due to the apparent	 low sensitivity and specificity. 
Recommendations go on to explain that	 the multi factorial falls assessment	 should be carried 
‘normally in the setting of a	 falls specialist	 service (1.1.2.1)’. 

These 	guidelines,	 like the JRCALC, help to provide a	 detailed picture of a	 patients overall capability 
but	 appear ill equipped to identify a	 patient	 who is at	 immediate risk of falls in ACA. 

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 The Investigation: 
Reviewing the investigation, it	 appears that	 not	 all pertinent	 details were reported. Below is a	 list	 of	 
questions that	 could have been informative in our future interventions. If any falls do occur in future 
similar questions should be asked in any subsequent	 investigation for BA to better learn and 
improve. Furthermore, it	 may be best	 to consider phone call or face to face interview for incidents 
that	 lead to patient	 harm to ensure as much detail is gathered as possible. 

Question 

1)  Is there any extrinsic cause for the fall? 

Use 
If we could identify extrinsic causes we could 
seek to limit	 these in patient	 areas 

a)  Was the floor slippery? 
b)  Did the patient	 have appropriate foot	 

wear? 

c)  Were any trip hazards present? 
d)  Does the patient	 normally use mobility 

aids 

2)  Why did the Emergency 	Department	 not	 
complete their Falls Risk Assessment? 

3)  Were there any other falls in ACA or ED 

recently? 

4)  What	 was the broader context	 of the 

fall? 

a)  What	 else was happening in the 
immediate area	 at	 the time? 

b)  Why was the clinician away from the 

area? 

D)  The patient	 was scored as Rockwood 

Frailty 3 (by the medical team) and 5 (by 
the surgical team) while in hospital. We 
do not	 know what	 the pre-hospital team 
scored the patient	 as we do not	 have 
access to those records. It	 appears the 
patients mobility was challenging to 
assess for multiple clinicians. Regardless 
a	 Rockwood 5 involves the patient	 
requiring	 mobility aids – were these 
available? Were they brought	 into the 
department 

This can help us to understand our gaps in 
communication and team-working with the ED 
department. 

Were there any similar falls in ACA or ED? If 
there were, were they adequately reported? If 
there were unreported falls, this could 
represent	 a	 blind spot	 in our Patient	 Safety and 
Quality Improvement	 processes. 
All of these would help us to accurately map 
what	 was happening when the fall occurred and 
we could more directly address issues that	 
contributed to the circumstances of the fall 

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 c)  Did the clinician take hand over directly? 
If so, was the patient	 highlighted as a	 
falls risk in handover? 

d)  Was the patient	 seen by  a	 hospital 

clinician prior to the fall? 

The	 System of 	Care: 
To better appreciate the context	 that	 this fall occurred within I	 created an AcciMap and a	 Human 
Factors Analysis and Classification System (HFACS) (Appendix	One)	 of the event	 from the information 
available. 

This helped to reveal the broader systems implication in the matter. Specifically: 

1)  There was ambiguity over who was ultimately responsible for ACA from a	 policy perspective 
2)  The dynamic work demands made patients and staff more vulnerable to this type of incident. 
3)  The human factors involved in ACA are significantly different	 from typical ambulance queuing. 

Point 	One: 
Within ACA there was ambiguity surrounding who has ultimate responsibility for the patients in the 
ACA. Policy states that	 the hospital has overall responsibility but	 that	 this is delegated to ambulance 
clinicians for observations, personal care and hydration. 

The 	work-as-prescribed in	policy is that	 the ACA is in an extension/projection of an ambulance 
queuing in the car park. However, the work-as-done in practice within	 the Emergency Department	 
was that	 the patients were assessed, and treated by hospital clinicians as if they were in-patients. To 
highlight	 this, plenty of the interventions that	 took place in ACA would not	 take place in ambulances 
but	 only in ACA e.g catheterization. Over time as this ambiguity continued this likely created a	 blind 
spot	 for ambulance and hospital staff alike as both parties may assume that	 that	 the other had 
completed work/risk-assessments/tasks for the patients when neither have.	 This	 could have 
contributed to the fact	 that	 the patient	 was triaged by an ED nurse and was not	 labelled a	 falls risk, 
despite the patient	 hitting several markers on the RUH risk assessment	 tool. 

Point 	Two: 
During background research into this event, I	 discussed ACA with several other paramedics who had 
worked there previously.	 Many of them describe several issues with the dynamic nature of the 
department. 

Often hospital clinicians would see, assess, manage, or move patients without	 the clinician being 
aware. This would happen because the paramedic was the clinician in charge as well as the liaison 
with ED and so would regularly be required to walk away from ACA to contact	 different	 sections of 

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 the ED. While they were gone the ACA situation would change and this could create blind spots for 
patient	 specific needs. 

Secondly, the paramedics describe a	 slow drift	 overtime of what	 the ACA was accepting. Over time as 
HALOS and charge nurses got	 accustomed to the ACA, they would need to adapt	 to the demands of 
the day and use ACA in ways it	 was not	 intended to, which pushed ACA outside of its Scope. 
Examples include HALOs asking ACA to briefly care for patients who were not	 suitable so crews could 
go home on time, or so other patients could be moved through the department. However, many 
times the brief period became extended to several hours. One case involved a	 patient	 who required 
BiPAP being placed in ACA. When the paramedic alerted the charge nurse they were told that	 this 
was not	 appropriate but	 there was no other space in the ED at	 this time and that	 they needed to ‘just	 
keep a	 close eye’ on the patient. 

This type of incident	 was not	 an isolated event. These incidents were raised to the ED staff as per the 
ACA policy, however, these were rarely done in writing, often verbally on the day. This likely 
prevented any one individual keeping track how often there were near misses in ACA due to its 
accidental and improvised misuse. 

Point 	Three 
From mapping the ACA system of care it	 is clear that	 the human factors involved are significantly 
different	 from typical ambulance work and typical ambulance queuing; multiple patients on hospital 
beds, often requiring protracted clinical and personal care.	 Furthermore,	 the typical ambulance staff 
to patient	 ratio is two to one,	 in ACA it	 can be a	 range up to three to seven. Reviewing the guidelines 
it	 appears inadequate to simply map current	 pre-hospital policies on to in-hospital patients 
regardless of the fact	 the pre-hospital clinicians are the ones caring for patients. 

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 Recommendation: 

Falls Risk	 Assessment Tool: 
As described the ergonomics and human factors involved in ACA are clearly different	 from a	 typical 
ambulance patient	 interaction.	The type of holistic risk assessment recommended by JRCALC cannot	 
be reliably implemented in a	 clinical context	 like ACA. This	recommended assessment	 is in-depth and 
necessarily time consuming, and would be unrealistic to implement	 in an ACA context	 due to ACA’s 
dynamic nature and high turnover of patients. We should therefore look to implement	 an adapted 
Falls Risk Assessment. 

As a	 starting place we	 should consider	employing	the risk assessment already	used in RUH ED.	This 
is a	 tool that	 BA could look to adapt and employ to highlight	 at	 risk patients as it	 uses several markers 
from the holistic approach to rule falls risk in or out	 for a	 given patient. In practice this will need to be 
implemented in conjunction with local trusts and adapted accordingly. 

ACA	 Risk	 Assessment: 
There is no documented falls risk assessment	 of ACA before its implementation. A pre-emptive in-
depth risk assessment	 would have likely identified the gap between pre-hospital in-hospital falls risk 
and	an intervention could have been enacted. For example, we	 could integrate with the current	 RUH	 
policy and procedures. Therefore, in future we should conduct a falls risk	 assessment and 
intervention	 strategy	 before implementing a	 cohorting area. 

Additionally,	ready	 access to	commodes	may	have 	been	identified	as	a	possible 	intervention	to	 
limit the risk	 of falls and	should	be 	considered	in	future 	cohort	areas. 

A key consideration in this incident	 it	 that	 the current	 guidelines are not	 sufficient	 to assess what	 is 
needed in ACA. What	 is need is a	 quick assessment	 of their immediate risk of falls. The holistic 
approach is brilliant	 for assessing there over all needs and for identifying how a	 multi-disciplinary 

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 team can help the patient. They are not sufficient	 to ascertain the patients level of falls risk in the 
ACA area. 

Appendix One: 

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 HFACS for ACA: 

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 Appendix Two: 

Pertinent	 Coroners Statements 

“The paramedic working within	 the cohort area	 did	 not complete a	 falls risk 
assessment in accordance	 with the	 JRCALC guidelines	 following	 the	 admission of a	 
patient who	 had	 just had	 a fall at home. “ 

“The other two	 ambulance staff did	 not seem to	 understand	 that Mr Cruse was a falls 
risk, 	they 	did 	not	consider	that	he 	was 	at	a 	greater	risk 	of	falls 	and 	did 	not	consider	 
that	 any	 further	 action should have been considered or	 taken.” 

“An investigation took place but the staff did not identify any learning and did not 
undertake the case study to	 help	 them identify such	 patients in	 the future. Bristol 
Ambulance Emergency Medical Services still run some cohort areas alongside South 
Western Ambulance NHS	 Foundation Trust, and continue to convey patients to 
hospital. The evidence given	 on	 behalf of this organisation	 did	 not provide reassurance 
that	 this is a matter	 which the ambulance service have adequately	 addressed.	 There is 
a	 real concern that	 ambulance staff	 throughout	 the organisation may	 not	 be 
adequately trained in recognising	 and dealing	 with patients	 who have	 had a	 fall or 
falls” 

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