NHS England case study: Inpatient falls and brain injury (23 July 2024)

Summary

This NHS England case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.

Content

Through its core work to review recorded patient safety events, the National Patient Safety Team identified issues with the assessment and management of brain injury following an inpatient fall, leading to delays in diagnosis and treatment.

A targeted review of falls reported to the National Reporting and Learning System (NRLS) over a one-year period identified deviation from NICE guidance on ‘Head injury: assessment and early management’ and variation in clinical assessment. This included differences in how neurological observations were taken, and delays in diagnostic interventions, including computerised tomography scans. Subsequent treatment and management were also impacted by these delays.

Reports also suggested significant deviation from NICE guidance on ‘Falls in older people’ regarding safe retrieval of patients from the floor, exacerbating patient discomfort and risk of further injury.

As a result of the review, it was highlighted that management of suspected traumatic brain injury following an inpatient fall should be an area of improvement focus for frontline clinical staff.  

NHS England worked with the Royal College of Physicians to successful apply to the Healthcare Quality Improvement Partnership (HQIP) to extend the scope of the National Audit of Inpatient Falls to include traumatic brain injury assessment and early management. This will help organisations to ensure they are meeting national best practice standards and allow the national programme to develop targeted resources.