Health & Safety

Case Study – Health board fined for failing to manage patients’ risk of falling (Wales)

A health board has been fined £250,000 following failures relating to patient falls in its hospitals.

Three elderly patients sustained falls in 2022 and 2023 and they all sadly died. The cause of death of two of them was identified as being as a direct result of falling.

The hospital concerned was initially investigated by the HSE following two other patient falls in 2020, one of which resulted in fatal injuries. As a result, the HSE took enforcement action against the health board that required it to implement an effective patient fall management system, including:

• Ensuring patients had appropriate falls risk assessments (with clear risk controls detailed)
• That the risk assessments were reviewed and updated accordingly in the event of a patient’s health deteriorating
• That staff received training on patient falls

The enforcement action also required the health board to review its patient falls policy and to ensure the entire system worked effectively. A follow-on inspection made in November 2021 identified that the health board was still not managing patient falls and this resulted in a further action being taken.

However, over the next two years, the three patients died and the health board had not implemented a system to identify and manage patient falls quickly or provide staff with updated training.

The health board pleaded guilty to breaching Section 3 (1) of the Health and Safety at work Act 1974, has been fined £250,000 and ordered to pay costs of £11,766.

Speaking after the case, the HSE inspector said ‘This is the second time this health board has been prosecuted in less than 18 months.

These incidents could so easily have been avoided had the health board followed their own adult falls policy. Effective management of patient falls includes thorough risk assessment, effective communication on risk management, monitoring and re-evaluation should the patient’s condition deteriorate.

Staff and agency workers need to follow the same training pathway, ensuring those responsible for falls management have the skills to make appropriate decisions.

Unfortunately, these actions were not always followed and as a result some patients suffered falls, which resulted in two preventable deaths.’

The HSE prosecution was brought by an HSE enforcement lawyer and paralegal officer.