Death after fall is under investigation

An investigation is under way after an elderly patient died after a fall in hospital.

The 87-year-old woman suffered serious injuries in August and the Taranaki District Health Board has launched an investigation.

Chief operating officer Gillian Campbell said in a statement the details surrounding the fall could not be released at this stage as the inquiry was ongoing.

It is not known if the fall occurred in the New Plymouth or Ha¯ wera hospital.

‘‘As with all internal investigations at our DHB, clinical staff from outside the area where the fall took place lead the review with the teams involved.

‘‘At times if the initial review indicates the need we will bring in someone external to undertake a review. This is unlikely in this situation.’’

The findings will be sent to the Serious Adverse Events committee and included in its public national report, which will be released in November 2018. ‘‘Sadly sometimes despite the best preventative measures falls do occur in hospitals,’’ Campbell said.

It is also highly likely there are other complicating factors that result in a patient dying from a fall in hospital, she said.

‘‘We would also like to acknowledge her family, as understandably, this has been upsetting for them.’’

The death was discussed at the hospital advisory committee meeting last week, with chairperson Kevin Nielsen describing the outcome as ‘‘tragic’’.

The fall was the first recorded to cause ‘‘serious harm’’ since two in January this year, a report tabled at the meeting revealed.

In total, 35 falls were recorded in August, resulting in a mix of serious, minor and no injuries.

In July 35 moderate and ‘‘no harm’’ falls were recorded, up from 23 moderate, minor and no harm incidents in June and 17 minor and no harm in May.

Nielson questioned the rise in numbers, saying they had ‘‘shot up’’. But director of nursing Catherine Byrne considered the rise to be somewhat ‘‘positive’’. ‘‘That’s actually OK,’’ she said. ‘‘I think what that’s actually representing is we’ve had an increased focus on falls and an increased focus on reporting the falls. It says we have an open culture, it says we have a reporting cultural. Actually, if that continues to increase that’s OK.’’

Nielson said he ‘‘naively’’ believed there was already an open culture of reporting.

Taranaki DHB has a falls risk assessment in place with plans developed for the patient following their assessment.

Byrne said falls were at times difficult to prevent and she was currently focused on prevention strategies. ‘‘We know that there is no one single intervention that we can undertake to prevent a fall. What it actually requires is a total systems approach and a multifactorial approach.

‘‘And then add to that as well that we do have an increasing population that’s elderly and frail and all of a sudden they, unfortunately, are in a very unfamiliar environment - it’s a large environment, there’s no longer the grab holds that they would normally grab hold of in hospital compared to what they’re used to at home.’’