Understaffing, gaps in cover for patients requiring constant supervision and low take-up of training among bank staff were among a series of wider problems highlighted by an investigation into the care of an elderly woman who fell while in hospital.
A Serious Incident Review carried out following the death of 86-year-old Denise Gwendoline Harris identified problems with staffing, training, record-keeping, policies and communication with families.
External investigator Julia Dutchman-Bailey concluded that the “root cause” of Mrs Harris’s fall was the absence of a member of staff able to provide continuous one-to-one care when she got out of bed.
Her report, which was read at Mrs Harris’s inquest yesterday, also warned that the “skills, knowledge and experience” of bank healthcare assistants were “very variable”, while bank staff were not paid to undertake education and training – meaning “take-up is low”.
Health and Care Jersey has since appointed specialist nurses, reviewed its approach to falls and one-to-one care, and introduced more compulsory training.
“Inadequate staffing arrangements”
Mrs Harris, known as Denny, was admitted to hospital with chest and urinary infections on 2 November 2025.
The inquest heard that she had previously seemed fit and healthy for her age, travelling to London with her family in August.
While recovering in hospital, she was suffering from acute delirium and was placed on a serious restriction of liberty – known to medical professionals as an SRoL – requiring constant one-to-one care.
But at 3.25am on 10 November, the staff member watching Mrs Harris went on a break, leaving a healthcare assistant to supervise her – among other patients and duties.
The healthcare assistant recalled sitting near Mrs Harris while working on her notes. When she saw Mrs Harris get out of bed, she jumped up to intervene but slipped and fell herself and was unable to stop Mrs Harris from falling.
Mrs Harris deteriorated over the following weeks and a CT scan revealed bleeds to her brain as a result of the fall. She died on 17 December 2025.
Ms Dutchman-Bailey found there was “inadequate staffing and staffing cover arrangements whilst members of the general ward team are taking their breaks”, with insufficient staff to provide one-to-one care to patients who required it.
“The root cause of the fall is that a member of staff to provide one-to-one continuous care was not in place to assist [Mrs Harris] when she got out of bed,” she said.
One of her recommendations was for the hospital to introduce a protocol covering breaks for staff providing one-to-one care. She also suggested a ceiling on new admissions and transfers when patients require such supervision.
Bank staff training take-up “low”
The review identified wider concerns about the training and experience of staff.
Those working on the ward on the night Mrs Harris fell were bank staff, and Ms Dutchman-Bailey noted that they were not paid to undertake education and training, “therefore take-up is low”.
“The skills, knowledge and experience of these bank healthcare assistants is very variable,” she said.
She recommended that healthcare assistants required to provide enhanced care should be given “underpinning knowledge”.
The investigation also identified “lapses” in documentation and described records as fragmented between paper and digital systems, with “multiple” risk assessments.
Some hospital policies and guidelines were also found to be “not clear in their messages and content”.
Other recommendations included updating the falls policy alongside “robust education and training”, specialist falls training for senior ward supervisors and improving communication with families.
The review also called for a “more holistic patient-centred approach involving the family” when next-of-kin request more communication, as well as improvements around nutrition and mouthcare.
Ms Dutchman-Bailey noted that work had already begun “since the incident and concerns raised by the next of kin”.
Ensuring “that this doesn’t happen again”
A senior nursing position has since been created to tackle avoidable risks, with nurse of 48 years David McKenna appointed Associate Chief Nurse for Harm-Free Care. A nurse specialising in falls has also been appointed.
Mr McKenna told Mrs Harris’s family at the inquest: “I will be working on this to do something different, so that this doesn’t happen again. I am really sorry.”
His work advising staff across the hospital has so far focused on falls and pressure injuries, while he said new policies had brought in more compulsory training and guidelines were being updated.
A project piloted on another ward had also reduced falls, he added.
“Corbière Ward was having about five or six falls a month. With the project we have got falls down to two in May, two in June, three in July,” the nurse said.
That included two incidents where patients were assisted to the floor, which Mr McKenna explained could sometimes be better than attempting to stop a fall.
“Love, laughter, kindness and strength”
Mrs Harris, originally from Lincoln, had lived in Jersey, England and Spain with her husband before they returned to Jersey to be with their grandchildren.
Her daughter Sarah said she loved cooking and always made space at the table.
“All were welcome and it would often turn into quite a party,” she said.
In a statement, the family said: “Mum’s life was one of love, devotion and resilience.
“She faced hardship with courage, embraced friendship with warmth, and poured love into her family.
“Every day we remember not only her story, but the love, laughter, kindness and strength she gave to us all.”
Review to reduce similar incidents happening
Tabetha Darmon, director of nursing, allied health professions, clinical governance and quality at Health and Care Jersey, said: “I would like to extend my sincere condolences to Mrs Harris’s family and loved ones.
“Following this case, we undertook a review to identify learning to reduce a similar incident happening in the future and to reduce the severity and frequency of patient falls.
“Since that investigation, HCJ has appointed a Falls and Frailty Nurse and a Harm Free Nurse who are reviewing the processes related to falls management within the hospital to ensure alignment with the Royal College of Physicians’ best-practice guidance.
“Furthermore, we are reviewing our arrangements to ensure that we consistently deliver one-to-one Enhanced Therapeutic Observations of Care when this is required.
“I would like to reassure Islanders that HCJ remains committed to the continuous improvement of our services, to ensure the highest standards of care for our patients.”
