Recurring concern

Unreliable response to falls at elderly people's homes

First to latest report 14 Feb 2019 — 12 Aug 2024

Reports that mention this concern
3
Times this concern has been raised
4
Stated actions linked to this concern
5

What this concern includes

Includes failures in the dedicated response to falls involving elderly people at home, including role and responsibility definition, initial assessment, recognition of serious injury, communication of assessment limitations, ambulance escalation and related response guidance or competence controls.

What is not included
  • Excludes generic care-provider role ambiguity where the asserted concern is not the response to a fall at an elderly person's home.
  • Excludes falls prevention, home-environment hazards and post-hospital treatment where the response to the fall is not deficient.
  • Excludes generic training, staffing or communication deficiencies unless they directly impair the dedicated response to an elderly person's fall.
  • Excludes unrelated clinical assessment or ambulance-response failures not connected to an elderly person who has fallen at home.

Reports and published responses 3 reports

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

  1. Liverpool and the Wirral

    AI-generated summary

    Douglas ARMSTRONG · 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

    Douglas ARMSTRONG had an unwitnessed fall at home on 16 December 2023 and sustained a fractured neck of femur that was not identified by care agency responders or a district nurse. His hospital arrival and likely surgery were delayed by around 18 hours, and he died in hospital on 5 January from aspiration pneumonia resulting from the injury. The principal concern was that responders may lack the skills, knowledge, training, or communication needed to identify such injuries or recognise when further assessment is required.

    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 of care responders to identify serious injuries from falls or recognise the limits of their diagnostic ability

    Wider context from the report

    “Following his fall at home the Deceased was visited by two representatives of the care agency. They did not appreciate that he had suffered a fractured neck of femur. They placed more reliance than was justified upon his assertion that he had not hurt himself and was not in pain. The information supplied during their verbal communication with the ambulance service did not result in the latter appreciating the need for a personal attendance or visual assessment. Fractured neck of femur is a common consequence of falls in the elderly and requires prompt attention. Those providing a response system should have the skills, knowledge and training necessary to identify the problem or to appreciate that they cannot do so, and to communicate the limits of their diagnostic ability to the ambulance service. I was told that the responders acted in accordance with their existing training and have had no additional training since these events, nor was I told that any is planned. I am concerned that responders attending a similar call might be unable to assist effectively and would appreciate their employers addressing this by considering whether opportunities exist to improve the situation. ”

    Source location

    Douglas ARMSTRONG · Prevention of Future Deaths report
    Page 1 · concerns

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    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 communicate the limits of responders' diagnostic ability to ambulance services

    Wider context from the report

    “Following his fall at home the Deceased was visited by two representatives of the care agency. They did not appreciate that he had suffered a fractured neck of femur. They placed more reliance than was justified upon his assertion that he had not hurt himself and was not in pain. The information supplied during their verbal communication with the ambulance service did not result in the latter appreciating the need for a personal attendance or visual assessment. Fractured neck of femur is a common consequence of falls in the elderly and requires prompt attention. Those providing a response system should have the skills, knowledge and training necessary to identify the problem or to appreciate that they cannot do so, and to communicate the limits of their diagnostic ability to the ambulance service. I was told that the responders acted in accordance with their existing training and have had no additional training since these events, nor was I told that any is planned. I am concerned that responders attending a similar call might be unable to assist effectively and would appreciate their employers addressing this by considering whether opportunities exist to improve the situation. ”

    Source location

    Douglas ARMSTRONG · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. East Riding and Hull

    AI-generated summary

    Harold Wilberforce · 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

    Harold Wilberforce fell at home on 16 January 2023, sustained a broken hip and was taken to hospital, where he contracted bronchopneumonia and died on 28 January 2023. Concerns included the lack of medical examination after the fall, the pharmacy delivery agent’s lack of awareness of his dementia, the absence of relevant staff training, and unclear roles and responsibilities when elderly service users are found to have fallen.

    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

    Lack of clarity about roles, responsibilities and required actions during falls at elderly service users' homes

    Wider context from the report

    “(3) I am concerned that a lack of clarity exists in respect of the roles and responsibilities of persons attending upon the home addresses of elderly service users, particularly in the context of what action should be taken when someone is found to have fallen. ”

    Source location

    Harold Wilberforce · Prevention of Future Deaths report
    Page 2 · 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

    Remind inspectors to discuss pharmacy procedures for responding when delivery agents find service users fallen or otherwise at risk.

    Verbatim wording from the response

    “We will also remind our inspectors to make sure that they include, through our ongoing inspections, discussions about whether a pharmacy has SOPs in place to support delivery agents/drivers and wider teams to know what to do and who to contact if they find that a service user has had a fall or is at risk in other ways. The inspectors do currently routinely ask about how pharmacies ensure that children and vulnerable adults are safeguarded. This means that we can check if pharmacies are proactively considering how to manage the risks associated with these situations.”

    Source location

    Response from General Pharmaceutical Council
    Page 3 · response
    Published 18 July 2023

    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

    Assess the pharmacy’s safeguarding risks and factor the concern into inspection timing and focus decisions.

    Verbatim wording from the response

    “From what has been described to us, on this occasion it does appear that there has been a failure to safeguard a vulnerable service-user. As the issues you have raised fall more into the category of how the pharmacy is being operated, we have referred the matter to our local Inspector who covers this particular pharmacy. They will assess the risks posed by the issues you have described, and determine what follow-up action may be appropriate. The Inspector will also factor this information into their decision-making”

    Source location

    Response from General Pharmaceutical Council
    Page 1 · response
    Published 18 July 2023

    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

    Inform delivery agents of their duty to contact emergency services and notify the pharmacist on duty after identifying an emergency.

    Verbatim wording from the response

    “As an organisation, we have taken steps to address this by making our delivery agents aware of their duty to contact emergency services and inform the pharmacist on duty as soon as practical.”

    Source location

    Response from Orchard 2000 Pharmacy
    Page 1 · response
    Published 18 July 2023

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    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

    Enrol all delivery agents on the Delivering Medicines Safely and Effectively training programme.

    Verbatim wording from the response

    “We have also contacted our staff training providers, the NPA, to identify any necessary update course for our delivery agents. They have responded by making us aware of a training programme titled: Delivering Medicines Safely and Effectively. We have reviewed the content of the course and are satisfied that this covers all the concerns and provides clarity for our staff in these circumstances.”

    Source location

    Response from Orchard 2000 Pharmacy
    Page 1 · response
    Published 18 July 2023

    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 regulator’s role covers registered pharmacists and pharmacy technicians, not unregistered delivery drivers.

    Verbatim wording from the response

    “In addition, not all those who work within a pharmacy company, such as delivery drivers, are required to be registered professionals, and our role only covers individuals who are registered pharmacists or pharmacy technicians.”

    Source location

    Response from General Pharmaceutical Council
    Page 1 · response
    Published 18 July 2023

    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

    Delivery drivers are not generally expected to receive training specifically for managing a service-user’s fall at home or to enter patients’ homes.

    Verbatim wording from the response

    “This matter relates to pharmacy support staff. The roles and responsibilities of pharmacy support staff, such as delivery drivers, will be defined by the pharmacy. They, however, must be suitably qualified for the roles that they do. GPhC requirements for the education and training of pharmacy support staff includes being able to recognise and raise appropriate safeguarding concerns, particularly involving vulnerable adults. However, delivery drivers would not be expected to receive training specifically with how to manage a situation where a service-user has had a fall at home, and would also not normally enter patient’s homes.”

    Source location

    Response from General Pharmaceutical Council
    Page 1 · response
    Published 18 July 2023

    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 pharmacy defines support staff roles, while its Superintendent pharmacist is responsible for ensuring their training and competencies meet requirements.

    Verbatim wording from the response

    “This matter relates to pharmacy support staff. The roles and responsibilities of pharmacy support staff, such as delivery drivers, will be defined by the pharmacy. They, however, must be suitably qualified for the roles that they do. GPhC requirements for the education and training of pharmacy support staff includes being able to recognise and raise appropriate safeguarding concerns, particularly involving vulnerable adults. However, delivery drivers would not be expected to receive training specifically with how to manage a situation where a service-user has had a fall at home, and would also not normally enter patient’s homes.”

    Source location

    Response from General Pharmaceutical Council
    Page 1 · response
    Published 18 July 2023

    Open published response

  3. Milton Keynes

    AI-generated summary

    Douglas Albert Walter MINNS · 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

    Douglas Albert Walter MINNS, aged 93, fell at home on 21 August 2018 and made an emergency call. He was attended by ambulance after approximately four hours, taken to hospital with subarachnoid and subdural bleeding, and died there on 22 August 2018. The principal concern was the withdrawal of a falls service and the resulting delay in responding to people who had fallen, particularly amid strains on the ambulance service.

    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

    Unavailability of a home-based falls response service

    Wider context from the report

    “During the course of the evidence it was explained to me that the provision of a falls service was withdrawn some years ago, the service would provide for someone to attend the home of the person who had fallen, get them on their feet, assess their wellbeing, serve a cup of tea and get them back into bed if required. If they required more urgent treatment, they would report to the ambulance service. The withdrawal of the service puts patient's lives at risk and, in view of the strains on the ambulance service, consideration should be given to re-introducing it. It is unacceptable for a 93 year old man to be left lying on the floor for four hours before someone responds. ”

    Source location

    Douglas Albert Walter MINNS · 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

    Operate a 24/7 Home 1st Rapids service providing rapid triage, home attendance, assessment and escalation for acute falls.

    Verbatim wording from the response

    “• A Home 1st Rapids service provided by our community provider, CNWL, comprising of experienced nurse practitioners and prescribers, who respond to a call from a GP, ambulance services or other allied health professional.”

    Source location

    2019-0052-Response-by-Milton-Keynes-CCG
    Page 1 · response
    Published 2 June 2019

    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

    Existing commissioned services sufficiently replace the discontinued falls service, covering acute, preventative and non-urgent community fall needs.

    Verbatim wording from the response

    “I hope the above description of commissioned services provides suitable assurance that although the original falls services was discontinued, it has been replaced by a 24/7 Home 1st Rapids service to deal with acute episodes of falling in the community; supported by two in office hours services which focus on prevention and non-urgent needs. The Home 1st Rapids service reflects the objectives of the original falls service in that they attend the home, carry out an assessment, make the individual comfortable and call an ambulance if required.”

    Source location

    2019-0052-Response-by-Milton-Keynes-CCG
    Page 2 · response
    Published 2 June 2019

    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