A pensioner who died of head injuries following multiple falls in Raigmore Hospital was not receiving the care he needed because of staff shortages, a court has heard.
NHS Highland has appeared in court and admitted breaching health and safety laws in relation to the care of Colin Lloyd, 78.
Inverness Sheriff Court was told when the pensioner arrived at the hospital he was assessed as being a mobile patient at “high risk” of falling and required one-to-one care.
However, despite repeated requests for additional nursing staff none were made available and Mr Lloyd suffered a series of falls on the ward, ultimately causing fatal injuries.
NHS Highland is now facing a large fine over his death – although the court was told any financial penalty could hit frontline services.
Following the case the health board released a statement and apologised for the “lasting hurt” caused to Mr Lloyd’s loved ones, saying: “We are sorry for letting them down.”
Request for nurses not fulfilled
Fiscal depute Trina Sinclair told the court that Mr Lloyd had been taken to Raigmore Hospital on February 6 2019 following a suspected fall at home.
On admission to ward 6A he was assessed as being a mobile patient who was at a “high risk” of further falls and bed rails were also deemed unsuitable, so he was classed as a patient that required one-to-one care from nurses.
“Mr Lloyd was not given one-to-one care, ” Ms Sinclair said, adding: “At 11.20pm on February 6 he rolled out of bed and hit his head.”
The patient was found “lying on the floor with blood from a new laceration on his forehead”.
The following day the charge nurse reviewed staffing and made a request for a bank nurse to be brought in to meet the need for one-to-one care.
“The bank request was not fulfilled on the 7th or 8th of February,” Ms Sinclair told the court.
‘Very deep regret at the failings’
Mr Lloyd had a “near miss” incident on February 8 and two further falls on February 12 and 14.
On one occasion the rails on his bed had been raised and Mr Lloyd appeared to have climbed over them and fallen.
He died on the ward on February 16 and the primary cause of death was given as “recurrent falls causing large left subdural haematoma”.
The fiscal depute told the court that NHS Highland had a previous conviction for a similar matter in 2015.
On that occasion health board was fined £40,000 after a “nil by mouth” patient was given sausages and mash and choked to death.
James South, from Aviemore, was being fed via a tube through his nose and had a sign in red letters above his bed at Raigmore Hospital indicating he should not be fed through his mouth.
That incident was described as “an isolated failure at operational level”.
Changes implemented since death
Representing NHS Highland in the case involving Mr Lloyd, Advocate Grant Markie said his client had since conducted an internal review and a tailored improvement plan had been implemented.
Measures put in place included the use of electronic rostering, new daily patient safety meetings to allow senior staff to understand current pressures and anticipate flow through the hospital for the next 24 hours and the use of a new real-time staffing resource to share information and facilitate “the movement of staff to the right place at the right time”.
He said: “On behalf of the Highland Health Board I wish to take this opportunity to express the very deep regret at the failings on behalf of the board which have given rise to the death of Mr Lloyd.”
He said that patient care was “at the very heart of the ethos of the health board” which works to “provide a safe and supportive environment to patients and staff”.
“The board recognises that in this instance they have fallen short,” he said.
‘We are sorry for letting them down’
Sheriff Robert Frazer deferred sentencing to next month, having noted the need that any financial penalty could result in funds being taken out of frontline services.
Scottish Conservatives leader and MSP for Highlands and Islands Douglas Ross described the case as “unbelievable”.
He told The Press and Journal: “This is a shocking case and there has been a litany of failings by NHS Highland, which they clearly accept with their guilty plea.
“It’s unbelievable that measures that could have prevented this were not put in place and tragically Mr Lloyd died as a result of injuries that could have been prevented.”
NHS Highland’s director of people and culture Fiona Hogg, who is also the board’s lead executive for health and safety, said: “We are deeply sorry for the failures identified in our care that led to the death of a patient at Raigmore Hospital in 2019.
“We recognise the lasting hurt this will have caused to those who loved and cared for Mr Lloyd and we are sorry for letting them down.
“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.”