Fall risks in hospitals: ensure adequate supervision | Protecteur du Citoyen
December 17, 2018

Fall risks in hospitals: ensure adequate supervision

Corps

Main sur le barreau d'un lit d'hôpital

The complaint

An elderly person was taken to hospital after falling. After surgery, she fell again. Her condition declined and she died not long afterwards. A family member complained to the Québec Ombudsman.

The investigation

  • An elderly woman fell at home and was taken to hospital.
  • Further to a surgery, she remained a few days on the surgical unit.
  • She fell again while she was there, which caused her condition to decline rapidly.
  • The woman died not long afterwards.
  • A family member complained to the Québec Ombudsman.
  • The investigation showed that the user was noticed as being at a high risk for falls.
  • That is why a physician asked that a staff member remain at the woman’s bedside as needed.
  • No one was assigned this task, even when the woman was agitated.
  • Instead, the woman was placed in a room near the nurses’ station.
  • A motion detector was also installed to alert the staff if she tried to get up without help.
  • These measures did not prevent the woman from falling.

The result

After the Québec Ombudsman intervened, the hospital issued reminders to the personnel concerned aimed at improving practices and decision-making when users are at risk for falls.


The Québec Ombudsman ensures that your rights are upheld in your dealings with Québec public services. Are you dissatisfied with the services of a Government of Québec department or agency? Or with those of a health and social services network institution (2nd level of recourse)? File a complaint with the Québec Ombudsman by calling 1-800-463-5070 or use our online complaint form.