The fall of a pa­tient from the fifth floor of a hos­pi­tal 1 No­vem­ber 2024

27.11.2024

The Safety Investigation Authority, Finland assessed the fall of an older person from the window of a patient room on the hospital’s fifth floor. The patient had been hospitalized in the Western Ostrobothnian Central Hospital in Kemi situated in the wellbeing services county of Lapland, on 1 November 2024. The patient was seriously injured due to the incident.

Events

An older person was a treated to the internal medicine and neurology ward of the Kemi Hospital. When arriving to the ward, the patient was confused on but his/her condition had improved and s/he was going to be discharged in the coming days.

Early in the morning, the patient broke the attachment of the ventilation window mechanism in the patient room, removed the insect screen installed in the ventilation window and fell from the window.

Early in the morning, when conducting their rounds at 5 o’clock, the nurses who had been on duty at the ward during the night shift noticed that the patient had gone missing and started searching for the patient. After the search, the patient was found outside, next to the building, on the ground. A nurse was helped by a physician from the acute ward and emergency care staff in assisting the patient.

The patient was seriously injured as a result of the fall and needed further treatment was taken for further treatment.

Background information

The wellbeing services county of Lapland organises healthcare and social welfare services in Kemi. Specialised medical care services are provided by Mehiläinen Länsi-Pohja Oy, which has been providing the services for the ward since June 2018. The property of the hospital building and its maintenance are the responsibility of the wellbeing services county of Lapland.

The patient had been treated at the ward since 21 October. During the incident, the ward was staffed at standard levels, and about half of the patient places were in use. The situation in the ward was calm.
Attention had been previously paid to the patient’s restlessness, which had led to placing the patient in a single-patient room. The patient had not been appointed a specific nurse during the incident. A nurse can be appointed for a patient who needs continuous assistance or surveillance based on a physician’s decision.

The room in which the patient was placed was located in the immediate vicinity of the nurses’ office, on the opposite side of the corridor. The door of the room was closed and a bell had been attached to the door to give a signal when the patient leaves his/her room and moves to the corridor. There was no camera surveillance in the patient’s room. The nurses had not noticed any abnormal noise coming from the patient’s room during the night.

The hospital’s air conditioning system was upgraded three years earlier as part of a roof renovation. During the previous renovation, the doors of the rooms had been upgraded less than 10 years earlier and they had good soundproofing. The doors of patient rooms had been upgraded in a previous renovation less than ten years earlier. The rooms had good soundproofing.

However, it was possible to open the ventilation window in the patient room to let in fresh air. The width of the open ventilation window when opened to its full extent was 28 centimetres.

The fall from the fifth floor of the hospital building was 14.8 metres.

Photo: On the left is a photo of the ven­ti­la­tion win­dow in the pa­tient room and on the right is a photo from the out­side of the hos­pi­tal build­ing where the win­dow in­volved in the ac­ci­dent is cir­cled.

Observations

The safety of hospital properties consists of measures and structural solutions to ensure the safety of patients, staff and visitors. This includes fire safety, electrical and water safety, access control, alarm systems, ventilation and the ergonomics of the facilities. Continuous maintenance of property safety is essential.

The hospital must be safe for any patient regardless of their condition or related unforeseen changes. Risk assessment should be carried out individually and continuously during patient care. As a patient’s condition changes, the realisation of client and patient safety must be ensured, which may require appointing a personal nurse to the patient to ensure patient safety or to increase the security capacity at the ward to ensure ward safety. Individual risk assessment is required to ensure the safety of the patient room for each patient.

The safety of windows in patient rooms is part of property safety. It must not be possible for patients to exit their rooms through a window. Window safety should be ensured as a part of hospital property safety. In this case, the patient’s confused state had been identified, but different means to ensure safety had not been fully charted in relation to the patient’s situation.

The adaptability of healthcare and social welfare facilities should support ensuring client and patient safety.

The Safety Investigation Authority has previously recommended measures related to ensuring the safety and patient safety of healthcare and social welfare properties. They have emphasised that property management must be proficient, systematic and sufficient in view of the activities and property features.

In addition, the Safety Investigation Authority has previously noted that appropriate assessment, identification and elimination of risks in healthcare and social welfare properties requires regular and conclusive examination.

The investigation was carried out asa preliminary investigation (Safety Investigation Act of Finland 525/2011, section 18).aBsed on the preliminary investigation , the Safety Investigation Authority does not initiate a safety investigation into the case.

Previous recommendations issued by the Safety Investigation Authority regarding the safety of healthcare and social welfare properties:

Building management in social welfare and health care services

Development of a self-monitoring plan

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