Health board admits failings that led to dementia patient's death

A health board has admitted safety failings that led to the death of a high-risk dementia patient at a mental health facility in Perth.

Andrea Imrie, 82, died on 13 January 2024, a week after she fell and sustained catastrophic head injuries after getting out of bed at Murray Royal Hospital.

Perth Sheriff Court heard an alarm had been removed from her bed the day before, and motion sensor alarms in her room failed to notify staff.

An NHS Tayside spokesperson said it was "deeply sorry for the pain and grief this has caused" and it had taken steps to prevent any similar incidents.

The court heard that Imrie had a history of falls where she had sustained significant injuries.

Her bed pan alarm - which would alert staff when she got out of bed - had been removed on 5 January 2024, the day before she fell.

It had been moved to a new patient's bed due to an equipment shortage.

Fiscal depute Lisa Duffus said staff had made a collective clinical decision that Imrie was "more settled" than the new patient, so her bed pan alarm could be "safely removed".

"They would not have made that decision if Tayside Health Board had ensured there were enough bed pad alarms for patients," Duffus added.

She said the Crown accepted that alarms could only operate to reduce the risk of falls, and could not be relied upon to prevent falls from happening on wards.

The court heard that a second alarm system, involving infra-red beams around the patient's room in Tummel Ward, also failed to work.

Duffus said staff were aware the infra-red alarm was not working because Imrie had got out of bed on the early hours of 6 January 2024 and it had not sounded.

Some time later, Imrie was heard to fall within her room and staff found her lying on her back with blood coming from her head.

She was taken to Ninewells Hospital for specialist treatment and a CT scan revealed she had suffered a large volume haemorrhage.

"Her condition deteriorated significantly and it became apparent her life could not be saved," said Duffus.

NHS Tayside admitted failing to ensure that patients who were assessed as being fall risks in Tummel Ward were not exposed to risks to their health and safety.

They failed to provide an adequate system of work for ensuring that room movement sensor alarms were checked daily to make sure they functioned properly, and failed to ensure the system of work was being followed.

The health board also admitted failing to have sufficient bed pad alarms available on 5 January 2024 for patients in the ward who required them.

Defence counsel Peter Gray offered the health board's apologies to Imrie's family and said the organisation accepted its failings contributed to her death.

He said the health board had issued advice to all of its sub-organisations about how to deal with the risk of falls just three months before the tragic incident.

Gray said the failings were "not in any sense deliberate and were isolated failings in the management of risks".

"It arose as a result of a genuine, but misplaced, opinion that the placing of sensors and bed alarms were suitable," he added.

He said the health board had since taken steps to prevent any repeat of the incident.

Sheriff Jennifer Bain KC said she had been given 500 pages of background documents earlier this week and deferred sentence to allow time to read them.