NHS Highland fined £180,000 for death of pensioner at Raigmore Hospital in Inverness
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The Highland Health Board has been fined £180,000 for the death of a pensioner that was put down to staff shortages.
NHS Highland was brought before Inverness Sheriff Court where it admitted responsibility for the death of 78-year-old Colin Lloyd.
He died on February 16, 2019, after three falls during his admission at a ward at the hospital during the previous 10 days.
The cause of death was determined as subdural haematoma, hypertension, ischaemic frontal lobe stroke and type two diabetes due to the falls.
The court heard he was deemed of a 'high risk' of falling over but that the nursing shortage situation meant that he was not adequately supervised.
Fiscal depute Trina Sinclair had previously told the court that Mr Lloyd was in need of one to one care which was not always available especially at night.
Mr Lloyd was initially admitted to hospital following a fall at home.
However Ms Sinclair said there were 'various nursing shortages during the period' when he was in the hospital.
During one occasion nursing staff heard a scream from his room and found he had rolled out of his bed and was bleeding from the scalp.
Defence advocate Grant Markie said the NHS board had 'deep regret' at the death of Mr Lloyd and that it had 'fallen short of high standards' in his care.
He added that NHS Highland admitted to 'failing to provide the adequate level of staff' which was 'more acute during the night shift'.
He outlined to the court a number of steps that had been taken by the health board in the aftermath of Mr Lloyd's death.
The charge stated that NHS Highland, listed as being head-quartered at Assynt House, Inverness, failed to put in place effective arrangements to ensure that those identified with a risk of falling had preventative measures to stop such incidents.
In doing so Mr Lloyd suffered repeated falls and suffered fatal head trauma, the charge further stated.
NHS Highland has now apologised for the incident.
A NHSH spokeswoman said: "We are deeply sorry for the failures identified in our care that led to the death of a patient at Raigmore Hospital in 2019.
"We recognise the lasting hurt this will have caused to those who loved and cared for Mr Lloyd and we are sorry for letting them down.
"Our internal review following the incident identified several areas of improvement and as a result we have made a number of changes to our systems and practice.
"This includes clearer, more responsive processes for escalating staff shortages, the introduction of volunteers to provide additional support and companionship for older people in the acute hospital setting, and enhanced training for staff caring for people who are at risk of falling."
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.”
The court heard 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.
However this proved difficult, especially at night, and when dealing with new admissions and other patients with enhanced care needs.
The prosecutor said 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.
