This case concerns the care provided to an elderly woman who sustained a fatal fall at Christchurch Hospital, Te Whatu Ora — Health New Zealand (formerly Canterbury District Health Board (CDHB)). The case highlights the importance of appropriate fall risk assessment and management for at risk consumers.
The woman was admitted to the Emergency Department (ED) at Christchurch Hospital. She had a history of “blackouts” and was taking regular diuretic and blood-thinner medication that had potential side-effects of dizziness and urinary frequency. These side-effects increased her risk of falling, and her blood-thinning medications increased her risk of bleeding if she fell and sustained an injury. Despite these risk factors, the woman was assessed by the ED nursing staff as having “no risk” of falling.
Following the woman’s admission to the ward, she had an unwitnessed fall, and died shortly afterwards.
The Deputy Commissioner considered that the woman should have been identified as being at risk of falling when she presented to the ED. The woman’s heightened risk of falling and sustaining a serious injury were not recognised and appropriately managed. Due to the incorrect assessment, there were no added safeguards put in place to prevent the woman from falling.
The Deputy Commissioner considered that by failing to take the relevant fall risk factors into account on admission, and by failing to recognise the heightened risk of falling and risk of harm associated with the medications, CDHB breached Right 4(1) of the Code of Health and Disability Services Consumers’ Rights.
The Deputy Commissioner recommended that CDHB provide a formal written apology to the woman’s family. The Deputy Commissioner also recommended that CDHB review its protocols for preventing hospital-acquired injuries, with a particular focus on elderly patients and the assessment and management of falls, as well as its protocols for managing patients at increased risk of harm associated with blood-thinning medication.