Kenneth Swift

“Although assessed as being at risk of falls and despite being positioned in a bay that was close to the Nurses' Station in the Ward for better observation, Mr [name redacted] was also recommended to have a falls sensor as he was observed by occupational therapist and physiotherapist trying to mobilise without supervision despite advice not to do so.”

“No falls sensor was immediately available- Mr [name redacted] was put on a 'waiting list' of 34 existing patients needing such equipment. The cost of a chair sensor was said to be £60; of a bed sensor £90. The Hospital was said to be in a tendering process to acquire such equipment. In the relevant Ward (AMU/AMB) 95% of the usual 30 patients (when full) at any one time would have been assessed at risk of falls. Four sensors have been acquired since Mr [name redacted] death for use at the present time in that Ward”

“Such a mechanism may have made staff aware that Mr [name redacted], an elderly man known to be capable of confusion and already suffering from infection that could be aggravated by immobility if injured, was mobilising unsupervised”

“That in this Ward at least there is the potential for future deaths resulting from, or the aggravation of, conditions by the consequences of falls in other patients”