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Sunday 23 October 2016
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Slipping up

The consequences of not having procedures in place if patients fall and injure themselves could be unpleasant for them and the practice. Are you aware of what should be done in case such accidents occur?

Imagine the scene, it is a miserable Monday morning in February, the wind is howling and the rain is lashing down. Your practice is bustling with patients coming and going, phones are ringing off the hook and the IT server has just crashed. No wonder no-one notices the old lady, Mrs Brown, going into the patient toilet, let alone realises that she has not come out again. Eventually, another patient discovers her lying on the wet tiled floor. You watch the duty doctor rush to the patient’s aid and wait with her until the ambulance arrives – but throughout all of this you are thinking, ‘we are in so much trouble’. Yes, of course, it was an accident – but one that could have easily been prevented.  

Health and safety legislation
Under the Health and Safety at Work etc Act 19741 you, as the practice manager, have a duty to ensure that the building – and “access to and egress from” - is, “as far as is reasonably practicable, safe and without risk to health”. Over and above this, there is a general duty on everyone to ensure the safety of others.
So what does your practice’s health and safety policy say about the practice’s flooring when the weather is bad or if it has just been cleaned? Anything? And while on the subject of cleaning, do you know which products your cleaners use to clean the floors? Under the Control of Substances Hazardous to Health 2002 (COSHH)2 you are required to regularly review the practice’s COSHH assessment – can you remember when you last did this? Did you check the tins in the cleaner’s cupboard?
Is your accident book up to date? In fact, do you have an accident book? Given that poor Mrs Brown has sustained a fracture requiring hospital treatment, you are obliged to report the accident under Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).3 This will likely bring the health and safety executive to your door – would you be able to stand up to a rigorous Health and Safety Executive (HSE) inspection? How long is it since you looked at the practice’s overall health and safety compliance?
No doubt Mrs Brown’s lawyer will be able to point out a few more transgressions to add to those above, so in order to appropriately respond to any legal challenge, you too will have to seek expert legal advice – and the sooner the better. That said, legal advice will be costly but you may have some cover via your defence membership scheme or practice insurance policies. Check the small print on these documents so that you are clear about what is available to you. If you do need to engage a lawyer, do you have a designated law firm for the practice and a good working relationship with a lawyer who is known to the practice? Or is appointing a lawyer something that is still on that ‘to do’ list? Perhaps now is the time to sort that? Whatever arrangements you decide on remember to let other members of the team know – just so that no-one goes off taking independent and expensive advice elsewhere.

Overall costs
Unfortunately, it will not be just the practice that this misadventure impacts on – there will be the ambulance crew, hospital admission via A&E, the cost of the surgery, the physiotherapist, the occupational therapist, those pricey bed days stretched to include the delayed discharge from hospital as Mrs Brown has no next of kin. Add to this the opportunity cost of what else these healthcare professionals could/would have been doing if your patient had not gone into the practice’s toilet. It is thought that the cost of falls to the NHS is more than £2.3 billion per annum.4
When, and if, Mrs Brown does finally come home the practice team input will include visits from the GPs and district nurses, more occupational therapists and practice attached social workers.
As she recovers, there will be repeat appointments with doctors and practice nurses. The alternative, a re-location to a care home is an entirely different set of balance sheets.
Besides direct financial costs, be aware there is a real possibility that staff involved at the time of the fall will experience stress or guilt, requiring time off work and/or counselling. Your own anxiety levels could be heightened as you attend to the legal process, the health and safety repercussions, handle press communications and worry about the finances.
The cost to the patient is no less important – it is fair to say that a fall can be a dramatic, indeed traumatic, incident at the time but the consequences can be life changing. Besides the obvious pain and injury, Mrs Brown may have reduced mobility and be less able to care for herself, potentially experiencing feelings of embarrassment, anxiety and distress. Understandably, she may fear further falls, which diminishes her confidence, preventing her from leaving her home and leading to social isolation and loneliness.
In this, all too real, situation she would require increasingly complex packages of care and, ultimately, a place in a residential care home would become the only option.5
Reducing the risk of falls
Although people can fall at any age, eg, tripping, fainting, becoming ill, it is well documented that the older population is much more likely to do so – 30% of people over 65 are at risk of a fall every year and this rises to 50% for those aged 80 and above (NICE, 2015). We are all aware of the increasing numbers of elderly people in our practice demographics – and the frequency with which these patients consult GPs and nurses. It would therefore make sense to ensure that we continually work to reduce the risk of patient falls and make the practice as safe as possible. These actions might include:
l Carrying out a review of the current flooring – those tiles in the patient’s toilet might look nice but are they really a good idea? If necessary, plan a replacement schedule.
l Consider if there are enough handrails and if they are in a good state of repair.
l Ensure all areas are well lit – and at all times.
l Hold regular health and safety training sessions for all staff.
l Encourage everyone in the team to continually look out for, and report, hazards, eg, trailing wires, clutter and frayed carpet.
l Arrange for all spills, drips and puddles to be dried up immediately – and put a wet floor sign in place.
l If re-building or designing a new build, ensure falls prevention is included when planning of the layout.
Proactive emergency planning
As well as taking preventative measures, it would be wise to have agreed emergency procedures in place ensuring that, should there be an incident, everyone in the team knows exactly what their role is (and is not), eg, admin clerical staff know to summon clinical help but that they should not attempt to lift the patient.
Clinical advice regarding falls can be found on defence organisation websites, such as Medical and Dental Defence Union of Scotland (MDDUS).6
Keep your emergency trolley well stocked with in-date drugs and dressings, ensuring all of the equipment is working, calibrated, with live batteries, and the oxygen cylinders, are regularly checked?.
Is everyone clear whose responsibility it is to check these?
The following might sound like a stupid question but, can all of the clinicians use all of the practice’s equipment?
I have seen GPs struggle to work out how to use the practice’s defibrillator and nurses finding it impossible to open the oxygen.
Knowing that the equipment is there is not enough. So, perhaps some discreet rehearsals would be a good and reassuring measure for everyone – team and patients alike. In fact, it would be no bad thing to have a mock-up of a patient fall to test team co-ordination, equipment and that all of the emergency procedures are as efficient as they could be.
Remember to provide adequate training for the staff responsible for writing up incidents, and near misses, completing witness statements and ensuring RIDDOR compliance.
Don’t forget to include yourself and at least some of the GP partners in this training!
Finally, review documentation and contact details for key stakeholders regularly to ensure these are still current.

Hindsight without the pain
Happily, Mrs Brown has recovered from her operation, is feeling much better and looking forward to going back to her lunch club to see her friends next month. She is very grateful for all the attention the practice team have given her. The team – and the practice manager in particular – is delighted too.
Obviously, Mrs Brown and her fall are fictitious but the scenario is not that far-fetched and the questions asked and points made are not unreasonable. My aim was to give you the luxury of hindsight without you having to experience the ordeal of an actual patient fall situation. Good luck reviewing those practice policies and procedures.

Anne Crandles, freelance practice management consultant in Edinburgh.

Health and Safety at Work etc Act 1974 (accessed 14 November 2015).
2. Health and Safety Executive. Control of Substances Hazardous to Health 2002 (accessed 14 November 2015).
3. Health and Safety Executive. Reporting of Incidents, Diseases and Dangerous  Occurrences Regulations 2013 (accessed 14 November 2015).
4. NICE Falls in older people: assessing risk and prevention (accessed 21 November 2015).
5. Northern Health Social Care Trust. A Community Based Falls Prevention Resource Pack 2010
(accessed 21 November 2015).
6. Medical and Dental Defence Union Scotland. Take Care With Patient Falls (2011) (accessed 21 November 2015).