Bay of Plenty District Health Board Summary

1 July 2014 to 30 June 2015

Serious Adverse Events (excluding mental health events) reported to Health Quality & Safety Commission

Description of Event

Review Findings


Follow Up

Inpatient fall resulting in fractured hip


Patient recalled sitting on the side of the bed and then being on the floor, thought their leg "just gave way".


No documented falls risk assessment. Despite this the risk of falls for this patient was identified and appropriate plan of care in place for mobilising.


Falls programme includes strategies to improve compliance with QSMs (quality and safety markers).


Intentional rounding includes checks of environment


Inpatient fall resulting in three fractures


Patient with history of osteoarthritis, who usually mobilised with walking frame and one person assist, was sitting up on the edge of bed. Patient got up and transferred to the lazy boy chair without assistance.


Patient had bare feet, this combined with the vinyl fabric of the lazy boy, which is a slippery surface, appears to have resulted in the patient falling. Fractures treated with conservative management.

Patient careplan should have included use of appropriate footwear which includes non-slip socks.


Falls programme includes availability of double sided non slip socks.


Inpatient fall resulting in fractured ribs


Unwitnessed fall. Patient complaining of pain stated they had a fall earlier in the bathroom and was assisted off the floor by someone in blue. Nobody could corroborate this.


Difficult to establish how fractured ribs were sustained.


Patient assessed as high falls risk with plan in place - mobilise with assistance, nurse in single room on low low bed with sensor mat.



Inpatient fall resulting in fractured collar bone


Falls risk assessment completed and documented had identified patient as high risk, history of previous fractures from falls. Discussed having bed rails up as enabler but patient declined this.


Patient in contact isolation. Had been getting intermittent confusion but was last observed sleeping. Patient explained they were reaching out of bed for Lotto scratch cards which had fallen on the floor and they tumbled out.



Inpatient fall resulting in fractured hip


Unwitnessed fall. Patient with multiple comorbidities including postural hypotension, elements of dementia with increased periods of confusion. Initial assessment identified patient as high risk of falls and needing assistance with mobility no further documented assessment ot plan of care following transfer to a ward. Family member present and willing to stay to ensure patient had constant supervision. Staff encouraged family member to go home indicating patient would receive the level of care they needed.


No evidence of nursing care plan completion although response to risk of falls documented on TrendCare handover sheets.

Falls programme includes strategies to improve compliance with QSMs.


Ongoing education regarding patient and family centred care and support persons.

Ongoing communication with the family member caring for this patient they presented their story to BOPDHB board and the story is used in ongoing education particularly around aspect of support person role and welcoming them to stay.

Inpatient fall resulting in fractured hip


Elderly patient with severe osteoarthritis and poor mobility assessed as high falls risk. Plan of care included patient being nursed on a low low bed to assist with transfer and at night, as it was this night it was positioned on its lowest point. Staff went to assist another person in the room during the night and found patient out of their bed and lying on the floor next to the bed.


This patients' comorbidity made them an extremely high risk of fracture.



Inpatient fall resulting in fractured hip


Patient was in communal lounge area mobilising independently and was walking past another client who was suffering from a condition causing involuntary movements and was knocked resulting in the patient losing their balance and falling to the ground.


Whilst in some aspects this was an unforeseen incident due to the unpredictability of both clients it does highlight the already identified hazards with the environment.

Environment not conducive to needs of clients who require wide spaces to manage behaviour.


Risk assessments need to be regularly reviewed and updated.


The environment is an identified hazard which is managed and monitored through the hazard register.

Regular audits of risk assessment .

Inpatient fall resulting in fractured pelvis


Assessed as able to mobilise with walking frame and assistance. Taken to bathroom by nurse, towels on floor from previous patient whilst nurse picking these up patient fell.

Principles of intentional rounding environment checks to be extended to all areas including bathrooms.


Inpatient fall resulting subdural haematoma


Patient with multiple comorbidities including a history of falls at home and previous brain bleeds had a fall resulting in new bleed.


Falls risk assessment completed and care plan documented, noting patient required assistance with mobilising. Patient appears to have got up unassisted to go to the toilet and fallen.



Inpatient fall resulting fractured pelvis


Frail patient with multiple comorbidities including osteoporosis. Falls risk assessment completed and careplan was walk with 1 x assistance and frame, requires assistance with sitting on the toilet and hygiene cares and safe transfer from toilet to stand.


Nursing staff assisted patient onto the toilet advising them to ring call bell when finished and left them unattended in the bathroom, for patient's privacy. Patient reports they thought they could manage to get off the toilet by themselves so did not use call bell.

The need to supervise patients that require it at all times included in ongoing education.


Inpatient fall resulting fractured hip


Elderly patient who had a documented falls risk assessment. High falls risk due to recent falls at home, able to mobilise with stick and assistance x1 from staff. Seen by staff five minutes prior to fall, no confusion and did not require assistance with anything. Patient subsequently mobilised independently to toilet without requesting assistance and fell fracturing hip below prosthesis.



Inpatient fall resulting fractured hip


Patient assessed as falls risk and requiring assistance rang the call bell but before it was answered, got up and used their walking frame. Whilst attempting to open the toilet door patient fell.


Contributing factors staff availability during meal breaks, size, weight and structure of bathroom door.



The importance of ensuring colleagues are aware of when staff take breaks so they can respond to call bells in absences.


The doors meet required standards but are an identified hazard for frail elderly.

Included in ongoing education.

Query removal of BIPAP (Bilevel Positive Airway Pressure) contributed to patient death


The patient was significantly compromised on arrival to hospital and their death as a result of their medical state was not unexpected. The review was undertaken due to concerns with management of BIPAP.


No HDU (High Dependency Unit) bed available initially, placed in APU (Admissions Planning Unit) and later transferred to ward, no evidence of re referral to HDU.


A number of recommendations were made in regard to:

  • placement of patients on BiPAP
  • medical review of patients on BiPAP
  • content of the BiPAP/cPAP order
  • education.

Subject to ongoing coroner and HDC investigation.

Last updated: November 21, 2019