Health board fined after vulnerable patient dies

NHS Highland pled guilty to a breach of health and safety regulations at Inverness Sheriff Court on 31 January 2023.  

The procurator fiscal depute told the court that Colin Lloyd was admitted to a surgical admissions ward at Raigmore Hospital, on 6 February 2019, following a fall at home. 

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. He was not given the one-to-one care he needed. 

He fell three times while in hospital. The first time 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 subsequent CT scan found bleeding on the brain. 

The second fall happened on 12 February. His third and final fall happened on 14 February. This re-opened the wound on his forehead. Another CT scan showed he had suffered further bleeding on the brain. 

Mr Lloyd’s condition continued to worsen. He died on the ward on 16 February 2019. 

Speaking after the sentencing, Debbie Carroll, who leads on health and safety investigations for the Crown Office and Procurator Fiscal Service (COPFS) said, “The tragic death of Colin Lloyd could have been prevented had suitable and sufficient measures been put in place.      

“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.” 

There were also several near misses during the period he was in hospital.  

Ward staff repeatedly made requests for additional nurses to support Mr Lloyd’s need for care and attempted to manage the situation as best they could. This proved difficult, especially at night, and when dealing with new admissions and other patients with enhanced care needs. 

The prosecutor stated that at the time 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.