Recurring concern

Unreliable fall-mat safety controls

First to latest report 15 Dec 2014 — 3 Jun 2025

Reports that mention this concern
14
Times this concern has been raised
18
Stated actions linked to this concern
20

What this concern includes

Includes failures of dedicated fall-mat systems, including crash mats, sensor mats and comparable bedside fall mats, where provision, suitability, coverage, positioning, wireless activation, alerting or associated operating instructions do not reliably support falls prevention or detection.

What is not included
  • Excludes general falls-risk assessment, supervision, staffing or post-fall response failures where no fall-mat control is deficient.
  • Excludes pressure-relief mats, pressure mats used for purposes other than falls detection, mattresses and other equipment unless the assertion specifically concerns a fall-mat system.
  • Excludes generic wireless, WiFi, alarm or equipment failures not directly tied to the safe operation of fall mats.
  • Excludes the underlying occurrence of a fall where no failure of a dedicated fall-mat control is identified.

Reports and published responses 14 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester West

    AI-generated summary

    Pauline Hayston · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Pauline Hayston, who had reduced mobility, frailty and recent falls, sustained an unwitnessed fall while attempting to mobilise as an inpatient and later died following a fractured neck of femur and resulting immobility. The concerns identified related to the reliability and fitness for purpose of the Rambledguard falls mats, the suitability of the wireless system when several mats were in use, and the absence of technical instructions for nursing staff about operational problems.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unsuitability of wireless WiFi activation when several fall mats are in proximity

    Wider context from the report

    “The evidence raises the following concerns: 1. The reliability of the Rambledguard fall mats and its fitness for purpose. 2. The suitability of a wireless “WiFi” activated where several fall mats are in place in proximity to each other. 3. Insertion of instructions to nursing staff where the operational integrity of an essential equipment to alleviate falls risks has been identified. ”

    Source location

    Pauline Hayston · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unreliability of Rambledguard fall mats for their intended purpose

    Wider context from the report

    “The evidence raises the following concerns: 1. The reliability of the Rambledguard fall mats and its fitness for purpose. 2. The suitability of a wireless “WiFi” activated where several fall mats are in place in proximity to each other. 3. Insertion of instructions to nursing staff where the operational integrity of an essential equipment to alleviate falls risks has been identified. ”

    Source location

    Pauline Hayston · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Wi-Fi is not involved in the fall mats’ processes and therefore cannot cause delays or cross-talk with other devices.

    Verbatim wording from the response

    “Firstly, I understand from Bolton NHS Foundation Trust that it has worked closely with Ramblegard Ltd to explore your concerns. I am advised that there is no issue in regard to Wi-Fi potentially causing a delay, or ‘cross-talking’, with other devices, as Wi-Fi is not involved in the processes.”

    Source location

    2017-0278-Response-by-Department-of-Health
    Page 1 · response
    Published 27 November 2017

    Open published response

  2. Norfolk

    AI-generated summary

    James Charles MALLETT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    James Charles Mallett, aged 93, was admitted to hospital after a fall at home and later sustained a fatal head injury in a further inpatient fall. Concerns included delayed medical attendance, unclear and untimely neurological observations, inadequate contemporaneous records, insufficient falls prevention, and nursing staff training and experience that were considered inadequate.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to use available movement-alert and fall-prevention equipment

    Wider context from the report

    “4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett. There was no falls planning or prevention, there was no care plan in place on this ward. There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement. The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor. ”

    Source location

    James Charles MALLETT · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Birmingham and Solihull

    AI-generated summary

    Roger Harold Tombs · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Roger Harold Tombs died at Queen Elizabeth Hospital on 4 May 2016 after being admitted following a fall at Sunrise Care Home. He had a history of learning disabilities and an increasing risk of falls; the medical cause of death included bronchopneumonia and severe traumatic brain injury. Concerns included the failure of fall sensor mats to sound an alert and the practice of placing them on top of crash mats, which may reduce their effectiveness.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to place fall sensor mats on a hard floor

    Wider context from the report

    “2. The instructions for use of the sensor mats state they should be placed on a hard floor. 3. The investigating police officer from the public protection unit gave evidence that she was concerned that the crash mats below the sensor mats would reduce the effectiveness of the sensor mats and this could possibly be the reason the mat didn’t sound (there were other possible explanations). 4. The evidence was that Sunrise of Knowle is still placing sensor mats on top of crash mats. 5. No expert opinion has been sought on this practice but the evidence of the investigating police officer was that the managing director of the local distributors of the mats told her this was an unsafe practice in his view. 6. It is my opinion that there is a risk that the effectiveness of the sensor mats is being reduced by placing them on crash mats and if this is the case they may not sound when vulnerable residents are mobilising especially when there is a risk of falls, injury and potentially death. ”

    Source location

    Roger Harold Tombs · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review team practice for issuing sensor-mat advice and training, confirming it is consistent and accurate.

    Verbatim wording from the response

    “As we are concerned to hear that Sunrise Care Home are still using the sensor mats incorrectly, and as a direct result of the issuing of the PFD Report, I have reviewed practice within the team in”

    Source location

    Roger-Tombs-Response
    Page 1 · response
    Published 26 February 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop and send care-home guidance outlining good practice in using sensor mats for borough-wide circulation.

    Verbatim wording from the response

    “Furthermore, to support the dissemination of this across the care home sector, a guidance document has been developed outlining good practice in the use of sensor mats and is enclosed for your reference. This was sent on 4 April 2017 to Theresa Scragg - Acting Strategic Commissioner for Older People, Solihull Metropolitan Borough Council (SMBC), for circulation throughout all care homes in the borough.”

    Source location

    Roger-Tombs-Response
    Page 2 · response
    Published 26 February 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The team’s standard guidance did not recommend placing sensor mats on crash mats; the care home appears to have misinterpreted it.

    Verbatim wording from the response

    “The Nurse Lead informed Ms Vaughan that neither she nor any other member of the team had been directly involved with the Mr Tombs’ care, and that the advice that had been provided to Sunrise was standard guidance on the appropriate use of crash mats and sensors. It was confirmed to Ms Vaughan that the standard guidance and training would not have advocated the use of the sensor mats being placed on top of crash mats. It can be only assumed that Sunrise Care Home have misinterpreted the advice provided by the Fall Team which is supplemented by the recommendation that each resident would also need a holistic risk assessment to ensure measures could be put in place to meet each individual’s need.”

    Source location

    Roger-Tombs-Response
    Page 1 · response
    Published 26 February 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Unable to describe measures implemented after 1 March 2017 because it will no longer manage the Home.

    Verbatim wording from the response

    “It is expected that SSL will be leaving the Home and will be deregistered by CQC on 1 March 2017, with another provider coming in to manage the Home and who will be registered with CQC. SOK remains registered with the CQC.”

    Source location

    2017-0027-Response-by-Sunrise-Senior-Living
    Page 1 · response
    Published 26 February 2017

    Open published response

  4. Manchester South

    AI-generated summary

    RHYS TUDOR WILLIAMS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    On 3 March 2014, RHYS TUDOR WILLIAMS was put to bed at Sunrise Senior Living and was found deceased between his bed and the wall at 1.40 am. The report raised concerns about inadequate staff training, incorrect bed positioning, failure to apply bed brakes, insufficient staffing and communication, pre-completed care notes, and possible delays in calling an ambulance.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure crash mats and sensor mats are provided on both sides of the bed

    Wider context from the report

    “2. Despite the assurances of the Managing Director, who was very frank and helpful in her evidence, I remained far from satisfied that all the staff members were aware of the rules relating to the positioning of the ‘profile beds’ which are on caster wheels. Because of this lack of certainty amongst the staff members, Dr Williams’ bed was placed, allegedly, against the wall when apparently this should not have been the case. Are all the staff members now clear as to the Rules relating to the positioning of the profile beds? Is there a rule about the need for crash mats and sensor mats on both sides of the bed? ”

    Source location

    RHYS TUDOR WILLIAMS · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Communicate the rule requiring crash mats and sensor pads on both sides of beds for residents at risk of falling, subject to risk-assessed exceptions.

    Verbatim wording from the response

    “If a person is at risk of falling from the bed and does not have bed rails, there is a clear general rule that beds will no longer be placed against walls and will have crash mats and sensors on both sides of the bed. This has been clearly communicated to staff across the group. Exceptions will be rare but may include cases where the resident has capacity and insists on the bed being placed against the wall. Any such cases will be fully risk-assessed and, as explained above, will involve the input of a regional training officer.”

    Source location

    2014-0558-Response-by-Sunrise-Senior-Living
    Page 2 · response
    Published 15 December 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Universal sensor and crash mats are unnecessary because fall-risk assessment determines when mats and sensors are required on both sides.

    Verbatim wording from the response

    “A blanket ban against placing beds against walls for those who are not at risk of falls is not proportionate. However, all staff are trained regarding the safety issues of placing beds against walls. This is now included in our moving and handling training and as such every carer and nurse team member is trained on an annual basis. Similarly there is not a rule of a need for sensor or crash mats on the side of each bed as this would be unnecessary for many residents who may be at low risk of falls. Risk of falling is assessed on admission and monthly at a minimum thereafter. As explained above, however, crash mats and sensor pads are now placed on both sides of the bed when a resident is at risk of falling unless exceptional circumstances apply.”

    Source location

    2014-0558-Response-by-Sunrise-Senior-Living
    Page 2 · response
    Published 15 December 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026