A patient died not long after four bathroom falls at a Bay of Plenty Hospital, according to a report from Deputy Health and Disability Commissioner which was released today.
The man, aged in his 80s, was left with a broken neck after the final fall, with another patient claiming it took 20 minutes before help arrived.
The report outlines the events leading up to the final fall which occurred in 2019.
The man first presented to a hospital's emergency department with acute and chronic abdominal pain. While in care at this hospital, it was decided he was a high falls risk due to his complex medical history.
His falls plan identified that he should not be left alone while in the hospital bathroom.
Upon discharge from this hospital, the man's pain continued and he presented at a second Bay of Plenty hospital some months later. A fall plan was put in place where he was not to be left alone on the toilet or once out of bed.
The report states Bay of Plenty DHB said it was made clear to the patient that he was to ask for assistance when getting up from his bed, and that if he went to the toilet he was to ring the call bell to be assisted back to bed.
However, the DHB noted that due to the long length of time the patient often spent on the toilet it was not possible to assign someone to wait for him to finish and the toilet door had to be shut for privacy and hygiene reasons.
"Bay of Plenty DHB said that the patient was reluctant to interrupt staff members to attend the toilet with him, but he was watched as closely as possible given other priorities in the ward at the time," the HDC report states.
However, the patient's wife claimed some hospital staff members had questioned the need for him to use the toilet as he had a nephrotic and suprapubic catheter. She said some staff had "walked away" from him when he asked to use the toilet, something the DHB apologised for.
"It was most regrettable that he was made to feel unsupported," the DHB said.
Over the course of the next few months, the patient had three falls in the bathroom, two of which happened on the same day. None of these falls resulted in serious injuries.
The final fall happened just over a month later when a nurse took the patient to the toilet around midday. While he was on the toilet he experienced severe pain and was given pain-killers, on three occasions a nurse said they had advised him to return to bed.
The patient called for assistance, but the nurse was unable to answer the call bell in "a timely manner", the report states.
The patient's wife told HDC that a patient in the same room said they heard her husband fall and "call out" and so they had pushed the call button repeatedly, but it had taken staff at least 20 minutes to attend.
"Bay of Plenty DHB said that the call bell shows on the communicator panels in the corridor, and the nurse has to step away from the patient being attended to check where the call has come from," the report said.
A nurse found the patient on the floor of the bathroom, claiming he had fallen while attempting to stand. His wife disputes this, saying he fell while trying to push the call button.
The nurse documented the patient was in pain with an injury on his head (a small skin tear on the left-hand side under his scalp) and a skin tear on his left knee.
After he was helped back to bed it was assessed he should have a CT-scan should his condition deteriorate, but his observations, including neurological observations, were within the normal range.
An incident report was completed by the nurse which documented that “in retrospect the patient needed either full supervision in the bathroom or to be returned to bed in the first instance".
The patient's wife said she wasn't informed of the fall and only officially found out after asking the DHB about the incident.
Bay of Plenty DHB acknowledged the patient should have been checked every few minutes, and should not have been left unattended on the toilet for 20 minutes.
A doctor then assessed the patient in the afternoon and decided his neck pain should be monitored but didn't find an "acute injury" which required an X-ray be taken.
Later that night, the patient was still complaining of neck pain and told the nurse he had broken his neck.
After just over a month of "extreme pain" a CT scan was taken that showed a fracture of the patient's second cervical vertebra, placing him at high risk of life-threatening complications.
He was transferred to palliative care where he died a short time later.
Official's response
Deputy Health and Disability Commissioner Deborah James issued a statement on the incident alongside the report.
"In my view, Bay of Plenty District Health Board (now Te Whatu Ora Hauora a Toi Bay of Plenty) had a responsibility to ensure the patient received care of an appropriate standard that complied with the Code. However, there were several issues with the care he received.
"These issues included the lack of critical thinking applied to the patient’s falls risk assessment in relation to his bathroom needs.
"There was also a consistent failure to adhere to his care plan and the falls policy was not followed by several nurses and doctors. In three cases the patient’s wife was not informed of her husband’s falls and after one fall an incident report was not completed.
"These inactions and/or failures by multiple staff members, and their failure to adhere to policies and procedures, demonstrate a pattern of poor care and a culture of non-compliance with policies. At a systemic level these failures had a negative impact on the care provided to the patient."
James gave a number of recommendations to the DHB after the incident which include providing a written apology to the man’s wife and training to all house officers and nurses on Te Whatu Ora Hauora a Toi Bay of Plenty’s falls management policy.
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