First reported 5 Nov 2013•Latest report 18 Dec 2024
Definition
What this concern includes
Includes failures of dedicated movement-alert systems for patients at high risk of falls, including unavailable or insufficient alarms, ineffective alert coverage, unsuitable alert arrangements and failures to provide an alternative alert or monitoring method when the usual alarm cannot be used.
Not included
Excludes general falls-risk assessment, supervision or post-fall response failures where no movement-alert control is deficient.
Excludes generic call-bell, patient-observation or alarm-system deficiencies unless they are specifically intended to alert staff to mobilisation by a patient at high risk of falls.
Excludes fall-mat failures where the asserted concern is limited to the operation of the fall mat rather than the wider movement-alert arrangement.
Excludes failures to act after a movement alert has been reliably received.
Reports
6
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2013–2024
First to latest report issue date
Stated actions
12
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Blackpool Teaching Hospitals NHS Foundation Trust1
Care Quality Commission1
County Durham and Darlington NHS Foundation Trust1
Durham Constabulary1
Durham County Council1
Excelcare Holdings Limited1
Four Seasons Health Care Group1
Information Commissioner's Office1
Medway Maritime Hospital1
Medway NHS Foundation Trust1
South London Healthcare NHS Trust1
The Limes1
The Queen Elizabeth Hospital, King's Lynn1
NHS trust4
Care-home operator2
Healthcare site2
English unitary authority1
Health and social care service regulator1
Information rights regulator1
Police force1
Residential care home1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
County Durham and Darlington
Concerns raised1
Failure to provide effective, individually tailored monitoring measures for residents at high risk of falls
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Apply the Group Falls Policy and supporting flowcharts covering falls protocols, referrals, care planning, risk assessment and post-fall actions.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Analyse falls incidents monthly, validate home practice through regional reviews and use trend monitoring to identify and address emerging risks.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Remind Home Managers about available falls-reduction equipment and include equipment availability in regular audits of home practice.
Stated by Four Seasons Health Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 13 January 2025.
Action
Review care plans and risk assessments after falls, near misses or other changes in need, updating them where required.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
It cannot be established that Mrs Savage would have responded better to a different sensor measure.
Stated by Four Seasons Health Care GroupDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Norfolk
Concerns raised1
Lack of an effective means to alert staff when very high-risk residents mobilise from bedrooms
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Mid Kent and Medway
Concerns raised1
Chronic shortages of falls alarm equipment for patients assessed as requiring it
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Purchase additional falls alarms, bed sensor pads and chair sensor pads to increase available equipment.
Stated by Medway NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 April 2021.
Action
Implement ward-level stocktaking, local stock monitoring and daily checks alongside the centrally held falls-equipment reserve.
Stated by Medway NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 April 2021.
Action
Identify budget and establish RFID tagging, logging and tracking for falls equipment.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Action
Disseminate and require compliance with the falls-equipment procurement and non-availability escalation procedure.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Action
Maintain up-to-date falls-equipment training for staff working predominantly nights.
Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2021.
Action
Remind appropriate staff to report and escalate falls-equipment shortages promptly.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Action
Require Clinical Engineering to notify the dedicated falls team of shortages and provide twice-yearly stock reports and annual stocktakes.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Action
Maintain 10 dedicated, tracked falls alarms in the Emergency Cupboard at all times.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Milton Keynes
Concerns raised1
Failure to provide sensor mats to residents assessed as at high risk of falling
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Norfolk
Concerns raised1
Failure to use available movement-alert and fall-prevention equipment
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Blackpool and the Fylde
Concerns raised1
Unavailability of alarms for high-risk patients requiring monitoring during mobilisation
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of dedicated movement-alert systems for patients at high risk of falls, including unavailable or insufficient alarms, ineffective alert coverage, unsuitable alert arrangements and failures to provide an alternative alert or monitoring method when the usual alarm cannot be used.
