Insufficiently qualified or inadequate numbers of staff probably contributed to the high incidence of falls at Mid Staffordshire Foundation Trust, the independent inquiry has concluded.
The report, by Robert Francis QC, said it had received “striking evidence” about the incidence of falls, some of which had led to serious injury.
“Many, if not all, took place unobserved by staff and too many were not reported to concerned relatives for too long, or only when they saw an injury for themselves,” it said.
The inquiry heard of an instance of a patient suffering a series of falls unobserved, “finally sustaining a fatal injury”.
The report questioned the accuracy of falls reporting.
It said: “The reason for the incidence of falls and other safety concerns was probably attributable to a combination of a high dependency level among the mix of patients combined with too few staff, or staff not sufficiently qualified to cope.
“Incidents of the type described to the inquiry should not have been able to happen or continue more than momentarily if proper risk assessment and observation were applied.”