Oliver Chapman, specialist personal injury lawyer based at Thomson Snell & Passmore’s Tunbridge Wells and Dartford (Thames Gateway) offices, has secured £11,800 for a claimant who suffered a bimalleolar fracture of her right ankle, having fallen in hospital.
The claimant, who was in her 80s, was admitted to Darent Valley Hospital having been unwell for two days with intermittent weakness to her right side. The paramedic crew reported seeing a possible TIA. Two people were required to transfer her and she was sweaty and clammy and unresponsive for 5 minutes whilst sitting on a commode. The impression recorded within the records was of a urinary tract infection and hypernatremia (low sodium levels, causing confusion).
Her mobility was poor and had significantly deteriorated over the past six weeks. IV antibiotics were planned.
No falls assessment was performed upon the claimant being admitted to hospital and over the course of the following weekend, no clinical notes were prepared.
After five days, the physiotherapist noted that the claimant continued to find standing difficult due to weariness, pain and reduced mobility. She questioned her ability for rehabilitation and suggested that she might require a care home. She documented that two people were required to help her stand from a sitting position.
That day, a STRATIFY falls risk assessment form was finally completed by a staff nurse. With regard to her level of capability when transferring from a bed to a chair, the claimant was awarded a score of 1 which suggested she required ‘major help’. With regard to her mobility, she was awarded a score of 2, which indicated that she ‘walked with the aid of one person’. This gave a total score of 3. A score of 0 equated to a ‘low risk’, a score of 1 ‘moderate risk’ and a score of 2 or above a ‘high risk’, which required the implementation of a falls care plan. A score of 3 was recorded, but this was incorrectly documented as a ‘moderate risk’ as opposed to a ‘high risk’. No falls care plan was completed.
The following morning, as the claimant was being transferred from a chair to a commode by one nurse only, she urinated and slipped. X-rays were performed and a bimalleolar fracture of her right ankle was confirmed.
We were instructed to investigate the claim and, having recovered the claimant’s medical records, instructed a nursing expert to review the standard of care received.
Given the claimant’s advanced age, she was very keen that the case be settled. She had not suffered any financial losses, and thus the claim was advanced in respect of pain, suffering and loss of amenity only. We made the following allegations against the hospital trust:-
- It was unacceptable that no falls risk assessment was performed within 24 hours of the claimant being admitted to hospital; it was unacceptable that a falls risk assessment was not performed until 5 days later.
- It was unacceptable that no generic moving and handling patient assessment was performed on the claimant’s admission or subsequently.
- It was unacceptable that when completing the STRATIFY falls risk assessment tool five days following admission, the nurse incorrectly documented a score of 3 as a ‘moderate risk’ of falls.
- Accordingly, it was unacceptable that a falls care plan was not prepared and implemented on that day.
- Indeed, the standard of care planning in general was very poor. The trust failed to undertake care plans for personal hygiene and dressing, eating and drinking, elimination, maintain a safe environment, preventing pressure sores, breathing/oxygen therapy and sleeping.
- It was unacceptable that on the day of the accident, the nurse failed to observe the physiotherapist’s observations made the following day regarding transfer as it was clearly documented that the claimant required 2 people to transfer. It was unacceptable that a transfer was attempted by just one person.
In terms of causation, we argued that had the STRATIFY falls risk assessments tool been completed appropriately, the falls care plan would have been implemented and appropriate measures put in place to reduce the risk of the claimant falling. Within 24 hours the claimant fell on transfer and sustained a bimalleolar fracture of her right ankle. On the balance of probabilities, the fall and injury would have been avoided if the trust had appropriate procedures in place.
The trust apparently accepted these allegations and accepted the claimant’s offer of settlement of £11,800. The case was dealt with in a swift manner which ensured the claimant promptly benefited from her damages and court proceedings were avoided.