A Scottish NHS board has been fined £180,000 over the death of a 78-year-old man who fell out of his hospital bed three times.
NHS Highland was fined on Tuesday after admitting to a breach of health and safety regulations at Inverness Sheriff’s Court on January 31.
The prosecution told the court that Colin Lloyd was admitted to Raigmore Hospital on February 6, 2019, following a fall at home.
It was assessed as being unsuitable for bed rails, but at “high risk” of falling and requiring individual attention and observation.
The room to which Mr. Lloyd was transferred was run by a nurse who looked after two six-bed rooms and assisted in triaging in another room, meaning he did not receive the necessary personal attention.
During his time in the hospital, he fell out of bed three times.
The first drop, on February 6, was discovered after a witness heard a scream in Mr Lloyd’s room.
He had a cut on his forehead and a CT scan found a brain hemorrhage.
The second drop occurred six days later, and a third drop occurred two days later.
This final fall reopened the head wound and Mr Lloyd suffered further bleeding to the brain.
His condition worsened and he died on the ward two days later.
During Mr Lloyd’s time at the hospital, the Crown Office said the court heard that staff repeatedly requested more nurses to help him deliver the care he needed as there were new admissions to attend to and other patients with enhanced care needs.
The prosecutor said that, at the time, there was no apparent overview of staffing requests across all wards or a formal system for escalating unfilled staffing requests or for reviewing the situation for alternative solutions.
Speaking after the sentencing, Debbie Carroll, from the Prosecutor’s Office of the Crown and Tax Service, said: “The tragic death of Colin Lloyd could have been prevented if adequate and sufficient measures had been taken.
“The Highland Board of Health did not have effective control measures and arrangements to prevent or mitigate falls for patients identified as being at risk and Colin Lloyd suffered fatal head trauma as a result.
“This prosecution should remind duty bearers that failure to manage and implement effective measures can have fatal consequences and they will be held accountable for this failure.”
NHS Highland has apologized for mistakes made in Mr Lloyd’s care.
Fiona Hogg, director of people and culture, said: “We deeply regret the identified failures in our care that led to the death of a patient at Raigmore Hospital in 2019.
“We recognize the lasting damage this will have caused to those who loved and cared for Mr. Lloyd and we are sorry to have let them down. Our internal post-incident review identified several areas for improvement, and as a result, we have made a number of changes to our systems and practices.
“This includes clearer and more responsive processes for growing staff shortages, the introduction of volunteers to provide additional support and companionship to older people in the acute hospital setting, and better training for staff caring for people running the risk of falling.
Health and Safety Executive (HSE) Inspector Penny Falconer said: “This incident could have been so easily prevented simply by carrying out the correct control measures and safe working practices.
“Organizations should be aware that HSE will not hesitate to take appropriate compliance action against those who do not meet required standards.”