An inpatient on your ward sustained a fractured neck of femur after an unwitnessed fall. The trust is conducting a patient safety incident investigation. As the registrar, what is your role?

Question

An 86-year-old woman with delirium fell overnight on a bay with one healthcare assistant covering. She sustained a fractured neck of femur and is now post-operative. The family have asked to meet the team.

Accepted Answer

My first responsibility is her ongoing care: adequate analgesia, active delirium management, orthogeriatric review, early mobilisation, a bone health assessment with a view to treatment, and a plan for rehabilitation. That has to be secure before anything else. Second, the duty of candour applies, and the family meeting is a legal obligation rather than a courtesy. I would make sure it happens promptly with a consultant present, that we apologise, explain honestly what happened and what we do not yet know, describe the investigation and what will change, and follow it up in writing. Third, I would ensure the incident is on Datix with a factual account, and I would document contemporaneously in the notes what I observed without speculating about cause, keeping the clinical record and the incident report separate. My contribution to the investigation would be a factual timeline and a clinical account. What I would push for is that the analysis stays at system level. The questions worth asking are about the staffing ratio and skill mix on a bay of delirious patients overnight, the visibility of that bay from the nurses' station, whether the multifactorial falls assessment and lying and standing blood pressures had been completed, whether her delirium had been formally identified with a 4AT, what sedating or antihypertensive medication she was on, and whether she had appropriate footwear and a plan for night-time toileting. I would be explicit that a decision to cover that bay with one healthcare assistant is an organisational decision, not a failure by the individual, because the fastest way to stop people reporting is to let an investigation land on the person nearest the patient. I would also make sure the staff involved are supported rather than left carrying it. Finally I would want the learning fed back to the ward and the actions to have owners and dates, and I would ask to hear what happened to the investigation.

Leading the Response to a Falls-Related Never Event

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