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Do falls and falls-injuries in hospital indicate negligent care—and how big is the risk? A retrospective analysis of the NHS Litigation Authority Database of clinical negligence claims, resulting from falls in hospitals in England 1995 to 2006
  1. D Oliver1,
  2. S Killick1,
  3. T Even1,
  4. M Willmott2
  1. 1
    Institute of Health Sciences, University of Reading, Reading, UK
  2. 2
    National Patient Safety Agency, London, UK
  1. Dr D Oliver, School of Health and Social Care and Institute of Health Sciences, University of Reading, London Road Campus, Reading RG1 5AQ, UK; d.oliver{at}reading.ac.uk

Abstract

Background: Accidental falls are very common in older hospital patients—accounting for 32% of reported adult patient safety incidents in UK National Health Service (NHS) hospitals and occurring with similar frequency in settings internationally. In countries where the population is ageing, and care is provided in inpatient settings, falls prevention is therefore a significant and growing risk-management issue. Falls may lead to a variety of harms and costs, are cited in formal complaints and can lead to claims of clinical negligence. The NHS Litigation Authority (NHSLA) negligence claims database provides a novel opportunity to systematically analyse such (falls-related) claims made against NHS organisations in England and to learn lessons for risk-management systems and claims recording.

Objectives: To describe the circumstances and injuries most frequently cited in falls-related claims; to investigate any association between the financial impact (total cost), and the circumstances of or injuries resulting from falls in “closed” claims; to draw lessons for falls risk management and for future data capture on falls incidents and resulting claims analysis; to identify priorities for future research.

Methods: A keyword search was run on the NHSLA claims database for April 1995 to February 2006, to identify all claims apparently relating to falls. Claims were excluded from further analysis if, on scrutiny, they had not resulted from falls, or if they were still “open” (ie, unresolved). From the narrative descriptions of closed claims (ie, those for which the financial outcome was known), we developed categories of “principal” and “secondary” injury/harm and “principal” and “contributory” circumstance of falls. For each category, it was determined whether cases had resulted in payment and what total payments (damages and costs) were awarded. The proportions of contribution-specific injuries or circumstances to the number of cases and to the overall costs incurred were compared in order to identify circumstances that tend to be more costly. Means were compared and tested through analysis of variance (ANOVA). The association between categorical variables was tested using the chi-square test.

Results: Of 668 claims identified by word search, 646 met inclusion criteria. The results presented are for the 479 of these that were “closed” at the time of the census. Of these, 290 (60.5%) had resulted in payment of costs or damages, with the overall total payment being £6 200 737 (mean payment £12 945).

All claims were settled out of court, so no legal rulings on establishing liability or causation of injury are available. “Falls whilst walking;” “from beds or trolleys” (“with and without bedrails applied”) or “transferring/from a chair” were the most frequent source of these claims (n = 308, 64.2%). Clear secondary contributory circumstances were identified in 190 (39.7%) of closed claims. The most common circumstances cited were “perioperative/procedural incidents” (60, 12.5%) and “requests for bedrails being ignored” (54, 11.3%). For primary injuries, “hip/femoral/pelvic fracture” accounted for 203 (42.4%) of closed claims with total payments of £3 228 781 (52.1% of all payments), with a mean payment £15 905 per closed case. A “secondary” contributory circumstance could be attributed in 133 (27.8%) of cases. Of these, “delay in diagnosis of injury,” “recurrent falls during admission” and “fatalities relating to falls” were the commonest circumstances (n = 59, 12.2%).

Discussion: Although falls are the highest volume patient safety incident reported in hospital trusts in England, they result in a relatively small number of negligence claims and receive a relatively low total payment (0.019% in both cases). The mean payment in closed claims is also relatively small. This may reflect the high average age of the people who fall and difficulty in establishing causation, especially where individuals are already frail when they fall. The patterns of claims and the narrative descriptions provide wider lessons for improving risk-management strategies. However, the inherent limitations and biases in the data routinely recorded for legal purposes suggest that for more informative research or actuarial claims analysis, more comprehensive and systematic data to be recorded for each incident claim are needed.

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Accidental falls are the most commonly reported patient safety incident in hospitals.1 Rates of four to 13 falls per 1000 bed days have been reported in research studies in developed countries, equating to as much as 12 falls per month in a fully occupied 28 bedded ward.23 Accidental falls are predominantly a problem of older people, and the proportion of older people in the population is increasing in developed countries; therefore, although the data and clinical negligence systems described in this paper are drawn from England, there are wider implications for hospitals in other countries. A recent analysis1 by the National Patient Safety Agency (NPSA) found that falls accounted for 206 350 (32.1%) of all reported patient safety incidents in 2005–6 in acute, community and mental health NHS hospital trusts in England. This probably underestimates the problem, as it is known that falls45 and other patient safety incidents6 are routinely under-reported and that many hospitals report inconsistently to the NPSA.1 The NPSA analysis showed that the median age of people reported as having fallen in hospital was 81 years. This is unsurprising, because people over 65 account for around 60% of admissions and 70% of bed days in general hospitals in the UK78 The proportion of older people in the population is increasing in developed countries, so there are implications for hospitals in other countries.

Around 30% of falls in hospital lead to recorded injury.12 It is estimated that 1–3% of falls in hospital lead to fractures, and some populations may be disproportionately affected—for example patients with bone fragility. Hip fracture has a particularly devastating impact, with a mortality of 30 per cent at 12 months for patients over 759 All falls, even those with apparently “minor” physical outcomes (eg, soft tissue injury), have a significant impact on patients, as they can lead to pain, disability, anxiety and loss of confidence.10 Falls also have serious consequences on rehabilitation and may prolong hospital stay, as well as precipitating moves to long-term care.11

Falls also have serious implications for staff who, in addition to dealing with falls-related complaints from patients’ relatives and maintaining a balance between care for all patients and ensuring the safety of “high risk” individuals, may also be anxious that falls could be cited as a failure in the duty of care (a crucial feature of successful clinical negligence claims).112 While some falls are potentially preventable, a risk-averse approach could be inimical to good clinical practice in promoting rehabilitation and respecting patients’ autonomy. Indeed, it has been suggested that “a unit with zero falls would be providing zero rehabilitation.”13

There is a considerable literature on the causes of falls in hospitals1415 and interventions to prevent falls.13916 However, analysis of incident reports and complaints demonstrates that falls and subsequent injuries remain a major risk. This paper presents the results of an analysis of the NHS Litigation Authority (NHSLA) database on closed clinical negligence claims relating to falls; first to provide a detailed descriptive analysis of the costs and payment of claims, second to assess the extent to which systematic analysis of clinical negligence claims involving falls provide learning for risk management and clinical practice and third to provide lessons for the future collections of claims data which might aid risk management.

The NHSLA has administered clinical negligence claims made against NHS organisations in England since 1995. Most of these claims are made against hospital trusts (approximately 90%). This paper does not describe in detail, the work of the NHSLA or legal procedures in the NHS in England, nor does it explore the tests for establishing negligence and procedures for assessing damages, as these are explained elsewhere.1719 However, in English common law, in order to establish clinical negligence, it needs to be established that, on the balance of probabilities, there was a breach in the duty of care to the patient and that this breach resulted in a harm which was foreseeable and reasonably preventable.20 In practice, meeting these tests can be difficult, and cases are frequently settled out of court. This is further encouraged by the Civil Procedure rules which promote alternative resolution of disputes (to avert claims in the first place) and discussion between expert witnesses in claims, which usually results in claims being settled out of court.20 The mean length of time from claim to resolution is 16 months.1 Therefore, many claims logged from 2004 onwards had yet to be decided at the time of our 2006 census and which could have resulted from falls incidents that had occurred months or years before the initial letter of claim was submitted.

AIMS

This study describes and analyses data on clinical negligence claims involving accidental falls in NHS hospital trusts in England from April 1995 to February 2006. It aims to:

  1. describe the circumstances and injuries most frequently cited in (closed) claims involving falls;

  2. investigate any association between the financial (total cost) and physical (injuries sustained) impacts and circumstances of falls in such closed claims;

  3. present the learning for falls risk management in hospitals which might be derived from these data; and

  4. suggest how this research could contribute to improving the systematic collection of data on falls and related claims in negligence, to aid further organisational learning and research.

METHODS

Data handling

Since its inception in 1995, the NHSLA has maintained a database of all the clinical negligence claims that it has handled in order to monitor the claims process. (The database is not primarily designed for research purposes.) This database includes a free text summary of the claim—including the circumstances, alleged contributory factors and injuries/harms, though it is not primarily intended for use in research. In order to identify claims in negligence, involving accidental falls in hospital, a keyword search was constructed by the NHSLA with the research team to identify all claims notified to the NHSLA between April 1995 and February 2006 and brought by patients aged 18 years or over in which falls, faints or fractures were mentioned in the free text claim description. We only searched for data from the clinical negligence scheme for trusts (CNST) which is specific to claims in clinical negligence and not for falls-related claims in non-clinical negligence which are covered by the risk-pooling scheme for trusts (RPST) (these are claims relating to accidents or injuries in non-clinical areas of hospital—often to staff or members of the public and not directly related to patient care). The data extracted from the database do not allow us to ascertain more detailed information about the type of hospital from which the claim resulted. The database fields obtained included: the free text claim description, cause of the claim, injuries claimed for, progress of the claim (“Closed,” “Open” or “Incident”—the latter indicating where the NHSLA is aware that a claim is being considered) and financial information (ie, damages claimed, actual costs and damages to both the hospital and claimant). The claims were anonymised by the NHSLA before being released to the research team to ensure no data identified claimants, patients or organisations. The NHSLA permitted use of the data, but formal research ethics committee approval was not required.

Two members of the research team (DO and SK) independently scrutinised the claim descriptions and excluded any claims where a fall (or resultant injury) was incidental. Claims were also excluded if there was insufficient detail to assess the circumstances of the fall or the injury sustained. The remaining claims were categorised, based on clinical face validity, by four parameters (listed in tables 1–4) being the “primary” and “main contributory” circumstances of fall and “primary” and “main secondary” injury sustained. Where there was disagreement between the two researchers, they agreed a final interpretation of each claim.

Table 1 Damages costs and overall financial costs by primary circumstances of claim*
Table 2 Damages costs and overall financial costs by secondary (contributory) circumstances of claim*
Table 3 Damages costs and overall financial costs by primary injury*
Table 4 Damages costs and overall financial costs by secondary injury*

Statistical methods

A claim was regarded as “closed” if so reported by NHSLA and “not closed” otherwise. Only closed claims were included, as the final financial outcome of other claims was not known at the time of analysis. The overall financial cost (OFC) of each closed claim was calculated by adding D+DC+CC, where D, DC and CC imply “Damages” (to hospital and claimant), “Defence Costs” and “Claimant Costs”, respectively (table 5). OFC and D were evaluated as outcome variables in relation to the primary circumstances, secondary contributory circumstances, primary injury and secondary pathology (tables 1–4). The extent to which specific circumstances contributed to the overall financial burden to the NHS was assessed by their overall cost. Circumstances that tended to be more costly were identified by their mean OFC per case and their contribution to the proportion of claims compared with the volume of OFC, and by testing the association between circumstances and OFC bands (of ⩽£5000, £5000–£50 000, ⩾£50 000). The “noise” in the system was assessed through evaluating the proportion of claims actually leading to payment. Means were compared and tested through analysis of variance ANOVA. Association between categorical variables was tested using the chi-square test. Statistical analysis was carried out in SAS 8.2 (SAS Institute, Cary).

Table 5 Damages, defence costs, claimant costs and overall financial costs for closed claims*

RESULTS

Volume of claims and circumstances of injury resulting from falls

A total of 668 claims were initially identified by the keyword search. Eighteen were rejected, as a fall was incidental to the claim and four because there was insufficient detail to describe either circumstances of fall or injury sustained, leaving 646. By February 2006, 159 (24.6%) of these claims were “open,” 479 “closed” (74.2%) and eight (1.2%) “incident.” Only the 479 closed claims (ie, those where the financial outcome was known) were subjected to further analysis, and it is only these claims which are discussed in the results below. Table 1 summarises the primary circumstances of falls described in all closed claims. Falls while walking, from beds or trolleys (with and without bedrails applied) or transferring from a chair accounted for most of the claims involving falls (n = 308, 64.2%). Table 2 describes secondary contributory circumstance. In 190 of the total 479 closed claims (39.7%), a clear secondary contributory circumstance was identified, of which the most common were “peri-operative/procedural” and “requests for bedrails being ignored” (12.5% and 11.3% of 479 closed cases, respectively). Tables 3 and 4 describe the categories of “primary” and “secondary” injuries. “Hip, femoral or pelvic fracture” accounted for 203 (42.4 %) of closed claims (table 3), and “Delay in diagnosis of injury” resulting from falls, “recurrent falls during admission” and “fatalities relating to falls” were the commonest identified secondary contributory circumstances (table 4).

Volume of financial costs

The total cost of closed claims involving falls (whether or not they resulted in the eventual award of damages or costs) brought between April 1995 and February 2006 was £6 200 737 (mean £12 945 per claim, SD £48 974), with payment of some kind being made in 290 (60.5%) of the total 479 closed cases (table 5) and in 70% or higher in “Trolley A&E” “Bed with Rails” (table 1), “Faulty Equipment” and “Environmental Hazard” (table 2) “Cerebral Bleeding” (table 3) and “Multiple Falls,” “Dependency,” or “MRSA” (table 4). The overall financial cost of damages was £3 665 204 (mean £7652 per claim, SD £38 756), with payment towards damages being made in 233 (48.6%) of the cases. The overall financial cost of claimant costs was £1 596 573 (mean £3333 per claim, SD £8369), with payment towards claimant costs being made in 206 (43.0%) of the cases. The total financial cost of defence costs was £938 960 (mean £1960 per claim, SD £5031), with payment towards defence costs being made in 185 (38.6%) of the cases (table 5). Hip, femoral or pelvic fracture accounted for 203 (42.4 %) of closed claims at a total cost of £3 228 781 (52.1% of all payments), with mean payments of £15 905. Primary cause, secondary cause, primary injury and secondary pathology each did not significantly affect either D damages or OFC (ANOVA). The primary injury was highly associated (p = 0.0005, chi-square test) with OFC bands (of ⩽£5000, £5000–£50 000, ⩾£50 000) with “Nerve Damage,” “Multiple or other Fractures,” “Cerebral Bleed,” “Dental Damage,” “Hip/Femoral/Pelvic Fracture” and “Wrist/Hand Fracture” being awarded ⩾£50 000 in 67%, 13%, 11%, 11%, 5% and 4% of cases, respectively. “Nerve Damage” contributed 4.5 times more to OFC than to the volume of claims (2.8% and 0.6%, respectively; table 3) and MRSA contributed 2.6 times more to OFC than to volume (5.5% and 2.1%, respectively; table 4).

DISCUSSION

Overall findings

This paper describes the first published observational analysis of NHSLA CNST data relating to falls in hospital, to be published in a peer-reviewed journal. This is the largest such observational claims analysis published. Although falls account for around 32% of all reported patient safety incidents in NHS hospital trusts (with over 205 000 in 2004–5 alone), clinical negligence claims involving falls (646, 0.019%) represent a very low proportion of the total number of claims (34 446) notified to the NHSLA between April 1995 and February 2006. The overall cost of closed claims involving falls (£6.20 million over 11 years), is also very small when compared with the total payments of claims. For instance, in 2003–4 alone, there were total payments in excess of £350 million.19 While the absolute volume of falls in hospital represents a major risk-management issue1 and while these falls have serious consequences for patients, staff and clinical practice, bed occupancy and resource utilisation, this analysis shows that falls constitute a relatively low financial risk purely in terms of litigation, especially compared with high-risk areas of practice such as obstetrics or elective surgery. This may contribute to the relatively low priority given to falls risk-management strategies in hospital.

The finding that such a devastating injury as a hip fracture still only attracts a mean financial cost of £15 905 (analysis of all closed claims) seems to confirm that the age of the patient is a factor in the apparently low financial impact of falls claims. As most falls affect older adults, the financial costs of loss of amenity or earning potential and long-term care are likely to be relatively small. Explanations for the apparently low financial risk could reflect differences between population groups (older people might be more reluctant or less able to complain and may have different expectations of care), as well as difficulties in establishing clinical negligence, causation, or breach in the duty of care with older patients who often have multiple comorbidities or disability, and are already at high risk of the adverse event (falls and falls injuries).

Injury or circumstances of fall and financial impact

About half the total paid is for “hip, femoral or pelvic fractures”—perhaps because this fracture is easily definable, commonly requires major surgery and carries a high morbidity and mortality. The most common primary circumstances were either “falls while walking,” “falls transferring/or in the chair” (perhaps in patients attempting to stand or transfer) and “from beds or trolleys” (“with or without bedrails applied”). By far the most frequently occurring secondary contributory circumstances are “failure to apply bedrails” and “peri-operative and peri-procedural” events.

Methodological limitations

There are four main methodological limitations in this study. First, the data are retrospective and may have biases due to the nature of demonstrating negligence (eg, falls from trolleys or beds may be more likely to result in a claim but could be relatively rare events). However, when these findings are triangulated with other data, for example the NPSA analysis of falls incident reports, the pattern of circumstances and consequences of falls in hospitals is very similar. Second, the thematic analysis is dependent on the narrative description in the database that was designed to monitor the claims process. This introduces two potential data-quality issues; inaccuracies or incompleteness in the description and error in categorising the circumstances and injuries. The use of two blinded assessors sought to minimise error in categorisation, and the categories were developed using clinical face validity. There was arbitrary aggregation of events which had some clinical heterogeneity which could introduce subjectivity; however, using a smaller number of categories helped to make analysis meaningful. Third, the anonymised dataset provided does not contain patient demographic information (eg, age, gender, comorbidity or length of stay, or type of hospital unit), inhibiting further comparison with other data on falls in hospitals (eg, incident reports) and all other claims. Fourth, due to the time lag between an incident occurring and a claim being made and the further delay between receipt of letter of claim and closure of the case, many of the claims in the database are still “open,” and so it is not possible to draw conclusions about their financial impact. Moreover, as discussed in the methods, the anonymised dataset obtained for this study did not contain demographic and clinical information about claimants (eg, age, gender, ethnicity, comorbidity) that would enable multivariate analysis to control for potential confounding factors. The difficulties of using these kinds of “inadvertent” data in quantitative analysis have been described by Vincent et al.21 They note that other limitations of claims data include: few adverse outcomes resulting in claims; a bias towards severe injuries; difficulties in calculating incidences due to a lack of denominator data; biases introduced by changes in practice; a partial reliance on “direct participants”; absence of rigorous comparison groups and outcome bias (ie, more information is available on successful closed claims). Nonetheless, the methods employed were the most rigorous possible in what was a pragmatic analysis of “inadvertent” data sources not originally intended for research purposes, and the limitations do not invalidate the usefulness of the findings.

Questions and scope for further research

It would be especially interesting to examine why few claims involving falls are brought, including the impact of the complaints procedure and alternative dispute resolution on the volume of clinical negligence claims involving falls.

Implications for risk management and clinical practice

The data presented here are specific to the NHS in England. However, they clearly have implications for other developed countries. Although the common law tests of negligence are similar in some other legal systems (notably North America, Australasia and former Commonwealth nations), there are well-documented differences in attitudes and behaviours regarding clinical negligence litigation and a variety of systems for dealing with such action. There is a clear steer in England to resolve complaints without recourse to such lengthy and resource-intensive action. However, the existence of a national database (the NHSLA) provides an opportunity to analyse additional data relating to falls and falls injuries, and as the underlying factors which lead to falls in clinical settings may be very similar, there are potential lessons for risk management for practitioners and institutions beyond the UK. This analysis has implications for practice in targeting interventions to prevent falls in England and other countries. Despite emerging evidence on interventions for secondary prevention of injuries such as softer flooring, adjustable beds or hip protectors, the best way to reduce the overall injury rate is clearly primary prevention to minimise falls.

The recurrence of the terms “delay in diagnosis” and “recurrent falls” in claims descriptions suggest that there is more that can be done to minimise adverse consequences once a fall occurs. Key learning for falls prevention from this analysis is that there should be more vigilance and supervision for patients who are: in bed; in the immediate vicinity of their bed while attempting to stand; at risk of falling off trolleys (the latter especially in accident and emergency departments of following surgical procedures or investigations). The appropriate use of bedrails and clear explanations about the reasons for non-use of bedrails are critical to the success of these preventive strategies.

Even though the primary aim of the NHSLA database is to monitor the claims process, it provides useful learning to be gained from it regarding data collection in England and other countries. The analysis reinforces recommendations for the development of the NHSLA database made by Vincent et al,21 who suggest that the collection of clinical negligence data could be developed in order to extend its usefulness for research and risk management. This would complement the approach to systematic analysis of patient safety incident reports being undertaken by the NPSA. Such an approach would enhance the methodological validity of detailed quantitative research in this area. Nevertheless, the low number of clinical negligence claims involving falls and the relatively low financial risk of these to NHS organisations may impact on the extent to which learning from claims influences hospital risk-management strategies.

REFERENCES

Footnotes

  • Competing interests: None.

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