A health board, NHS Highland has been fined £180,000 after a vulnerable pensioner died while being treated at a hospital.
Colin Lloyd, 78, died after suffering three falls while in the care of Raigmore Hospital in 2019.
The court heard how his death could have been prevented if “suitable and sufficient” hospital measures were in place.
NHS Highland were handed the fine after pleading guilty to a breach of health and safety regulations at Inverness Sheriff Court on January 31 this year.
The health board said it is “deeply sorry” and ” recognise the lasting hurt this will have caused to those who loved and cared for Mr Lloyd”.
He was assessed by staff as unsuitable for bed rails but was at “high risk” of falling and required one-to-one care and observation.
However, the court heard how he was not given the one-on-one care he required and 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.
While in hospital Mr Lloyd fell three times.
The first incident occurred on February 6 when a witness heard a scream from his 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 Mr Lloyd’s brain.
The second fall occurred on February 12 and a third on February 14.
The wound on his forehead was re-opened and another CT scan showed he had suffered further bleeding on the brain.
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.”
Prosecutors say there were also several near misses during the period he was in hospital.
It was found that staff on the ward repeatedly made requests for additional nurses to support Mr Lloyd’s needs and attempted to manage the situation as best they could.
However, the lack of staffing resulted in difficulties particularly at night when nurses were 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.
A spokesperson for NHS Highland 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.”
