Failure to manage an elderly man’s risk of falling

Press Release – Office of the Health and Disability Commissioner

Deputy Health and Disability Commissioner Rose Wall today released a report finding Auckland District Health Board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to adequately assess and manage an elderly man’s risk of falling.

The man had Parkinson’s disease, a cognitive impairment and high blood pressure. He took regular medications, which had the effect of lowering his blood pressure.

Following surgery, he was discharged home with a catheter, but there were issues around the DHB’s communication with the man and his family about catheter education, and a referral to the District Nursing Service to assist with catheter care.

The man returned to the emergency department a few days later with catheter leakage and blood in his urine. He was assessed as a high risk for falls but no plan was put in place to prevent him falling. He was given medication, in addition to his regular medication, which had the side effect of lowering his blood pressure, but the DHB did not reconcile the man’s regular medications with what he was prescribed in hospital.

The man had a fall in hospital, but although his falls risk score was increased, no plan to prevent falls was put in place. He was later found to have low blood pressure and, soon afterwards, he had an unwitnessed fall that resulted in forehead lacerations and a spine fracture. He subsequently developed a haematoma and died a short time later.

Ms Wall considered that there was inadequate assessment and planning around the man’s falls risk to minimise harm to him, saying that “accurate care planning is one of the foundations of clinical decision-making”. She noted that the man was given several medications known to cause low blood pressure, but none of the staff queried his medicines or reviewed them after he had a fall.

“This case illustrates the challenging circumstances DHB clinicians must accommodate and manage appropriately when treating patients such as [this man] who had complex health and disability conditions – within a mainstream secondary or tertiary service environment.”

The DHB has since refined its falls assessment and care planning in line with Health Quality & Safety Commission guidance, and its medicine reconciliation processes. Ms Wall recommended that the DHB apologise to the man’s family and audit the changes it had made.

The full report for case 17HDC01195 is available on the HDC website.


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