Vulnerable patient died 'due to lack of nursing staff'

Colin Lloyd was admitted to Raigmore Hospital in February 2019

NHS Highland has been fined £180,000 following the death of a vulnerable patient at Raigmore Hospital in Inverness.

Colin Lloyd, 78, was admitted after falling at home. He went on to fall three times while in hospital, suffering bleeding on his brain.

The Crown Office said there had been a lack of nursing staff and he was not given the one-to-one care he needed.

Prosecutors said Mr Lloyd's death could have been prevented.

The fine came after NHS Highland pleaded guilty to a breach of health and safety regulations at Inverness Sheriff Court on 31 January. 

Following sentencing, the health board said it was deeply sorry for the failings identified in the patient's care.

The court heard Mr Lloyd was admitted to a surgical admissions ward at Raigmore on 6 February 2019.

He was assessed as unsuitable for bed rails but was at "high risk" of falling and he required one-to-one care and observation.

Mr Lloyd was transferred to a room managed by a staff nurse who was looking after two rooms of six beds and assisting in triage in another room.

Condition worsened

The first time Mr Lloyd fell in hospital was in the late evening of 6 February.

A witness heard a scream from Mr Lloyd's room and found him lying on the floor next to his bed with a cut on his forehead. A CT scan found bleeding on the brain.

The second fall happened on 12 February.

His third and final fall was on 14 February. This re-opened the wound on his forehead and a CT scan showed he had suffered further bleeding on the brain.

Mr Lloyd's condition continued to worsen and he died on the ward on 16 February.

The Crown said there were several near-misses during his time in hospital.

Ward staff repeatedly made requests for additional nurses to support his need for care and attempted to manage the situation as best they could.

The Crown said this proved difficult, especially at night, and when dealing with new admissions and other patients with enhanced care needs.

Prosecutors said there was no apparent overall view of staffing requests across wards or formal system in place to escalate unfilled staffing requests or to review the situation to look for alternative solutions.

'Lasting hurt'

Speaking after the sentencing, Debbie Carroll, who leads on health and safety investigations for the Crown Office and Procurator Fiscal Service, said his death could have been prevented.

Ms Carroll said: "Highland health board failed to have effective arrangements and control measures were in place to prevent or mitigate falls to patients identified as being at risk and as a result Colin Lloyd suffered fatal head trauma.

"This prosecution should remind duty holders that a failure to manage and implement effective measures can have fatal consequences and they will be held accountable for this failure."

Fiona Hogg, director of people and culture at NHS Highland, said the health board recognised the lasting hurt caused to those who loved and cared for Mr Lloyd.

She said: "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."

Gillian Tait, Royal College of Nursing Scotland senior officer for Highland, said more needed to be done to tackle nursing staff shortages.

She said: "This tragic case is evidence of the real toll the nursing workforce crisis is having on individuals and their families and on nursing staff.

"There are just too few staff to provide safe and effective care. The persistently high number of vacant nursing posts and increasing numbers of nurses leaving the profession means that patient lives are being put at risk.

"Nurses are under constant pressure and stress, are regularly working extra, unpaid hours to cover staffing gaps and are then going home feeling like they've been unable to provide the quality of care that they want. The toll this takes on staff wellbeing cannot be overestimated."