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Patient died after falling out of bed due to lack of nursing staff

Lack of nurses meant vulnerable patient did not receive the care he needed, despite staff requests, court hears before imposing fine of £180,000
Raigmore Hospital with signboard in front of building

Lack of nurses meant vulnerable patient did not receive the care he needed, despite staff requests, court hears before imposing fine of £180,000

Raigmore Hospital with signboard in front of building
Raigmore Hospital Picture: Alamy

A Scottish health board has been fined £180,000 after the death of a vulnerable patient due to a lack of nursing staff.

Colin Lloyd, 78, was admitted to Raigmore Hospital in Inverness, run by NHS Highland Health Board, on 6 February 2019 after a fall at home. While at the hospital he fell from his bed three times, suffering bleeding on his brain, Inverness Sheriff Court was told.

The Crown Office and Procurator Fiscal Service, which investigated his death, said there was a lack of nursing staff and Mr Lloyd was not given the one-to-one care he needed. He was assessed as unsuitable for bed rails but was still at high risk of a fall.

He was transferred to a room managed by a staff nurse who was responsible for overseeing two rooms of six beds and assisting with triage in another room.

Lack of nursing staff made it particularly difficult to manage his care at night, court told

The first fall during his time in hospital, on 6 February, 2019, was discovered after a witness heard a scream from Mr Lloyd’s room and found him lying on the floor with a cut on his forehead. A subsequent CT found bleeding on the brain.

Mr Lloyd fell again on 12 February and a third time on 14 February. The third fall re-opened the wound on his forehead and a new CT found he had suffered further bleeding on the brain. His condition deteriorated and he died on 16 February.

During Mr Lloyd’s stay in hospital, ward staff repeatedly made requests for additional nurses to support his care, the Crown Office said. The lack of nursing staff made it particularly difficult to manage his care at night and when dealing with other patients with enhanced care needs.

NHS Highland says it has identified areas of improvement and made changes to systems and practice

The prosecutor stated that at the time there was no apparent overall view of staffing requests across wards, or formal system in place to escalate unfilled staffing requests or to review the situation to look for alternative solutions.

NHS Highland pleaded guilty on 31 January to a breach of health and safety regulations and has apologised for failures made during Mr Lloyd’s care.

NHS Highland director of people and culture Fiona Hogg said: ‘Our internal review following the incident identified several areas of improvement and as a result we have made a number of changes to our systems and practice.

‘This includes clearer, more responsive processes for escalating staff shortages, the introduction of volunteers to provide additional support and companionship for older people in the acute hospital setting, and enhanced training for staff caring for people who are at risk of falling.’


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