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Failure to Monitor Fall Risk

$160,000 – Wrongful Death; Medical Malpractice/Negligence


A broken hip from a fall at a behavioral health unit requiring surgery leads to the death of an 89-year-old who had to cease her antidepressants, developed fluid overload, and bedsores.

On Nov, 27th, plaintiffs’ decedent MH, 89, died roughly 22 days after she fell at the UCSD Medical Center Senior Behavioral Health Unit. The previous May, MH’s brother passed away, and she began exhibiting signs of depression. In October, she was admitted to Tri-City Medical Center, where she was diagnosed with major depression and noted to be at high risk for falls because of problems with strength, balance and endurance. She was transferred to the behavioral health unit with her adult children’s permission. The transfer decision was based on statements by personnel of the Regents of the University of California that the behavioral health unit was a safe, supportive and responsive treatment environment. At the unit, MH was assessed as a high fall risk based on her weakness and unsteady gait. Her depression was initially treated with medication, without improvement, and followed in November by electroconvulsive therapy, which had a noticeably positive effect after the fifth treatment.

On Nov. 4, one day after the fifth treatment, MH fell next to her bed and sustained a rib fracture. On Nov, 6, MH underwent another ECT treatment, and her treating physician concluded that she had either fully recovered or nearly recovered from her depression. The following day, a nurse assisted her to the bathroom, but she fell after using the bathroom because she was left unattended and was not assisted back to her bed. At the time, MH frequently used the bathroom because of a urinary tract infection. She was using Ambien, a sleep-aid medication with the known side effect of increasing falling risk. MH sustained a femoral fracture of the right hip, which was treated with Tylenol until she could be transferred to internal medicine for hip surgery.

Her psychiatric therapy abruptly stopped when she was transferred out of the behavioral health unit, and her depression returned to its full extent. Her caloric intake became minimal to nonexistent, but she was not placed on tube feedings for over one month. After her hip surgery, she developed sodium and fluid overload, pulmonary fibrosis which required high-flow oxygen, and a Stage II decubitus ulcer. MH died on Nov. 27.


Her two adult children sued the Regents of the University of California for wrongful death and medical malpractice. They alleged that the defendant was neglectful and reckless in its care and treatment by failing to protect Holmes from safety hazards, including falls. They alleged that the abrupt cessation at her psychiatric care was detrimental to her overall health and well-being. They further alleged that the defendant failed to prevent or treat her dehydration and malnutrition, and violated its own internal policies and procedures for patients at high risk for falls.

The defense argued that the defendant’s care and treatment was not below the standard, and that it did not fail to meet accepted standards for adequate medical and psychiatric treatment of the elderly. The defense also argued that Holmes’s falls were caused by her failure to follow the nurses’ instructions. The defense also argued that MH failed to follow instructions from doctors and family members because she had lost the will to live. The defense acknowledged that the nurse made an error in judgment in leaving MH in the bathroom unattended, which was contrary to hospital policy.


MH was fully independent and able to cope with all activities of daily living, including managing her own finances and taxes, entertaining, and babysitting her grandchildren. Her heirs sought an unspecified amount in wrongful death damages.

Special Notes

Non-economic damages are capped in medical negligence cases.




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