Woman died at Hawke’s Bay Hospital after falling from bed, health and disability commissioner says

An elderly patient who was found face-down on the ground next to her hospital bed later died from a head injury suffered in the fall.

Now an inquiry has found "multiple deviations" from hospital policies before the 88-year-old woman suffered a fall at Hawke's Bay Hospital.

According to a report released by the health and disability commissioner this week, nurses found the woman next to her bed about 12.15pm on April 17, 2022.

The woman, who had a history of falling and had broken her hip in a fall at home the previous year, was initially unresponsive.

When she came to she was disoriented, agitated, confused and had clear signs of a head injury, with a laceration and bruising.

A CT scan found internal bleeding and fractures to the left side of her face.

The head injury was considered "non-survivable" and the woman, who was not named, was provided with palliative care until she died.

A coroner became involved and referred the case to the HDC, who has now found that Health NZ, which administers Hawke's Bay Hospital, breached the code of patient rights.

The woman was taken to the hospital's Emergency Department (ED) after another fall at home on April 15, 2022, in which she fractured four ribs.

"[The woman] had a history of falls and, although this was considered in the ED, it was not considered when she transferred to the ward," Deputy Health and Disability Commissioner Rose Wall said.

"Her history of falls-related incidents should have been taken into account and assessed appropriately, as acknowledged by Health NZ.

"In my view, there were multiple deviations from Health NZ policies and procedures in relation to [her] care ... If these policies and procedures had been followed, it likely would have mitigated these events."

Wall said that Health NZ was in breach of the code of patient rights in the woman's case.

She recommended Health NZ provide a written apology to the woman's family for the failings identified in her report.

However, she also acknowledged that Health NZ had made "significant changes" and "appropriate remedial actions".

Among those changes was extra training for staff - the number of nurses and care assistants who had completed modules in reducing harm from falls had now risen from 52 percent and 68 percent, respectively, to more than 80 percent overall.

David Warrington, Health NZ's group director of operations - Hawke's Bay, said the agency acknowledged the findings of the report.

"We extend our sincere condolences to her family and loved ones for their loss and unreservedly apologise for the shortcomings in the care she received while in our hospital," he said.

Warrington said that since receiving the report and after a comprehensive review, a number of improvements have been implemented across Hawke's Bay Hospital.

These included the introduction of falls prevention care bundles, weekly audits of patient risk assessments, high compliance with falls prevention learning modules, and ongoing hospital-wide monitoring of falls risk assessment compliance.

Falls management policies and guidelines had been refreshed and staff education and training had been increased.

Additional measures included the rollout of falls sensor mats across inpatient areas, work to strengthen the identification and communication of falls risks from the ED to inpatient wards, and a review of handover processes to ensure patient risks were clearly communicated between clinical teams.

"While these changes cannot undo the distress experienced by the family, Health New Zealand is committed to learning from this event and continuing to strengthen patient safety systems to reduce the risk of similar incidents occurring in the future," Warrington said.