The damning graph Freo Hospital refuses to explain

• The hospital briefing note shows that less than halfway through the financial year, its budget for Assistants in Nursing (AIN) had blown out by roughly 50 per cent.

 

• The documents show nurses were being asked how they’d cope with a reduction in the Assistant in Nursing (AIN) workforce. One later said their strategy would be “take a risk and see how it goes”.

 

• Nursing unit managers (NUMs) would not get fill-ins if an assistant (AIN) called in sick.

 

Whistleblower claims hospital falls cover-up 

A WHISTLEBLOWER claims WA’s health department has been covering up a dramatic increase in patient falls and serious injuries at Fremantle Hospital over the last three years.

The anonymous whistleblower gave the Herald internal documents from the South Metropolitan Health Service (SMHS), which runs Fremantle and Fiona Stanley hospitals, that show the number of falls recorded at the hospital suddenly doubled in November 2018.

The documents include a “briefing note” from a November 9 meeting showing senior staff were under pressure to rein in a budget for nursing assistants which had already blown out by 36 per cent and was described as “not sustainable”.

One of the main roles of nursing assistants is to be an extra pair of eyes and hands to prevent falls.

SMHS issued a statement to the Herald saying any claims of a reduction in nursing assistants was “false” and the workforce “in fact increased in all ward areas”.

But the department has ignored repeated requests for hard data to show whether any other cause of the increase in falls was identified and whether they were subsequently reduced to the hospital’s own benchmark level.

Restructure

The briefing note also seems at odds with the department’s claim.

“Topics for consideration” raised with nursing staff in the lead-up to a hospital restructure in late November that year included: “If the [Assistants in Nursing] workforce was reduced within the ward environment. What [sic] strategies would you implement to manage the workload?”

A risk analysis rates the potential for “level of harm to patients” as “high”, while another point specifies that if an assistant called in sick, they would not be replaced.

The briefing note does hint at a level of discontent amongst nurses about assistants being assigned to watch a specific room, with feedback noting “some sit outside rooms, play on the phones”, while those not part of the “team” were not invested in the wards.

Following the restructure the department adopted a new system of assessing and monitoring falls known as Falls Risk Assessment and Management Plan (FRAMP). 

The whistleblower says it is able to be manipulated to mask the number and severity of falls, having the effect of avoiding scrutiny.

Incidents within the hospital such as falls are allocated a “Severity Assessment Code”, with a SAC1 being for anything that leads to “serious harm or death”. SAC1s are automatically referred to a Clinical Outcomes Review Committee which reports directly to SMHS’s executive.

Reviewing requests for x-rays and scans for falls within the hospital against patient records shows that in one ward alone, between November 2018 and May 2020, there were 28 falls which resulted in one fatal brain injury, three bone fractures and four haematomas; yet just one SAC1 appeared to be registered. There were two SAC2 reports, corresponding to “moderate” harm which are not referred to the committee.

On another ward, an 87-year-old man who’d been admitted to the hospital with cellulitis and bacteria in his bloodstream had a fall at 8am on December 11 – just a month after the introduction of the new regime. Initially he was cleared to continue his rehabilitation for a hip injury sustained in September that year, but his condition deteriorated that evening and a brain haemorrhage was discovered.

Haemorrhage

A week later staff noted the “likely progression” of the man’s haemorrhage as his “coma scale” rating plummeted. He was diagnosed with a stroke and sent to Fiona Stanley Hospital for palliative care.

Despite his subsequent death on December 27, the fall was recorded as a lowest-level SAC3.

The whistleblower believes the hospital may have used his death at another facility as an excuse to record the lower SAC.

The Herald spoke to the man’s son, who said he didn’t notice any staffing shortages on the ward, and even thought the night shift was quieter than other health facilities where buzzers went off throughout the night. He said the nursing staff did a great job.

But the family was unhappy that during a previous stay at Fremantle Hospital for the injured hip, the man was moved without warning to a Jupiter Aged Care facility.

“Jupiter told us they weren’t funded for physio, so instead of getting up once a day and moving around as he had at Fremantle, they were only going to do it once a week, and he was deteriorating,” the son said.

“By the time he went back to Freo the second time, he was very unsteady on his feet.”

When the family queried why he’d been moved without contacting them, they were told the hospital needed the bed.

The son told the Herald he was convinced that decision played a decisive role in his father’s death.

The whistleblower says senior hospital staff have also used an in-built bias in the FRAMP system to justify downgrading SAC ratings for falls.

As an example, on January 3, 2019 a patient suffered a fractured femur after falling in the shower. It was initially reported by the nursing staff as a SAC1, but after review was downgraded to a SAC3 because no “system or process issues” could be identified that could have prevented the falls.

Ignored

The whistleblower says that’s only because the previous model of nursing assistants is ignored as no longer considered part of the system, so any assessment of whether the measures to rein in the budget have impacted on patient safety wouldn’t get kicked up the chain of command.

SMHS said it “wouldn’t comment on specific cases given patient confidentiality”, but also had no problem ignoring broader questions, such as the number of falls in particular wards and how many were unwitnessed (that stands at an average around 70 per cent).

But it did say the department took patient safety seriously.

“At the time in question, the AIN workforce was decentralised with AINs being integrated within the teams to address not only patient safety but staff satisfaction. Although there may have been a perception that the AIN workforce was reduced it in fact increased in all wards areas,” the statement said.

“The focus was on establishing a substantive AIN workforce, who would be part of the team, and the hospital would be less reliant on agency and casual staff.

“Given the above it would be tenuous to correlate what you understand/believe to be an increase in falls with a supposed decrease in AINs on wards.

“FH (Fremanlte Hospital) staff have a strong reporting and investigative culture to review and develop programs to help prevent patient falls especially given the hospital’s cohort of patients tend to be more susceptible to falls.

Specialised

“FH provides specialised aged care services and has a large number of dedicated geriatric medical beds, including beds for patients recovering from strokes and other major neuro-debilitating conditions.

“Given the age of the patient cohort, fall prevention continues to be a key area of clinical practice focus.

“To ensure this patient cohort is effectively supported during their inpatient stay and reduce the risk of falls, FH has initiated many strategies including: 

 • pre-fall huddles for individual assessment of falls risk patients and 1:1 falls prevention education for these patients by allied health and nursing staff; 

• use of falls prevention equipment for suitable at risk patients; 

 • introduction of the person-centred volunteer program to enhance engagement and completion of valued activities to ensure patients feel emotionally supported during their admission. This has been shown to reduce anxiety and agitation which is a major falls risk for people with dementia and delirium; 

• introduction of a revised Falls Risk Management Form with additional risk factors to be considered for patients with cognitive impairments. This was supported by widespread education and staff forums to ensure greater awareness of the increased falls risks of people living with dementia and experiencing delirium; 

• redevelopment of the garden outside B Block, Level 5 including a complete replacement of the paving area to give both same level paving and accessibility to people requiring walking assistance, plus paver colour discrimination for the visually impaired; and, 

• modifying ward bathrooms to reduce slip hazards, provide better accessibility and improve lighting. 

“These changes are part of the redevelopment and refurbishment of FH, creating a centre of excellence for elderly patients in the South Metropolitan region as part of a state government funding boost to redevelop and expand services at the site to meet the growing needs of the community. 

Disclaimer: The Herald traced the front page graph’s trend line in red for a more readable contrast, and reduced the pixelation in the title, but it didn’t affect the contents.

KNOW MORE ABOUT THIS? Contact the Herald on news@ fremantleherald.com 

by STEVE GRANT

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