Recurring concern
Unreliable documentation of falls and related clinical response
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Request correctionFirst reported 31 Oct 2013•Latest report 26 Feb 2026
What this concern includes
Includes failures to clearly and sufficiently record a fall, relevant symptoms or injuries, measures taken to seek medical advice, and related fall-care information needed for ongoing care, handover or review.
Not included
- Excludes general clinical or care-record deficiencies unrelated to falls or the response to a fall.
- Excludes failures to assess, treat or escalate a fall when the documentation of the fall and response was adequate.
- Excludes failures in falls prevention, supervision or post-fall clinical care where documentation is not the shared unsafe condition.
- Reports
- 20
- Individual concerns
- 20
- Date range
- 2013–2026
- Stated actions
- 23
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to record falls
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.2
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Action
Introduce a mandatory post-fall care bundle and checklist requiring structured assessment, neurological observations, escalation triggers and clinical documentation.
Stated by Barts Health NHS Trust -
Action
Reinforce contemporaneous documentation and communication of inpatient falls and significant safety events during nursing and medical handovers.
Stated by Barts Health NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.
Stated by Department of Health and Social Care
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Concerns raised1
Unclear documentation of falls, symptoms and measures taken to seek medical input
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Have managers immediately review incident forms for detail, completeness and clinical appropriateness.
Stated by Premiere Health Limited -
Action
Strengthen falls management and post-incident observation procedures for documenting falls, assessments and escalation reasoning.
Stated by Premiere Health Limited -
Action
Use mandatory post-fall observation charts for unwitnessed or potentially injurious falls.
Stated by Premiere Health Limited
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Action
Provide care staff refresher training in incident reporting and falls management.
Stated by Premiere Health Limited
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Concerns raised1
Failure to keep adequate records of falls care
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
There is no record or evidence that the patient experienced a fall during admission.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Position
The Trust disputes that Mr Horton experienced a fall during admission, stating that no record or evidence of a fall exists.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Deficient recording of key events following unwitnessed falls in nursing home records
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to record an inpatient fall on the discharge letter
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.1
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Action
Add a mandatory discharge-summary question covering inpatient falls and other safety incidents, and monitor it during implementation.
Stated by the Rotherham NHS Foundation Trust
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Concerns raised1
Failure to record significant post-fall injuries in care notes
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 concernsEach 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.3
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Action
Deliver mandatory refresher training on falls, head-injury recognition, recording, and escalation protocols to all care staff.
Stated by Daryel Care -
Action
Enhance digital photographic injury-upload capability, obtaining explicit client consent in accordance with policy, to supplement written care-note descriptions.
Stated by Daryel Care -
Action
Update care-documentation guidance and training with structured prompts for detailed injury descriptions and recording the rationale for non-escalation after initial reporting.
Stated by Daryel Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The fall and developing injury were recorded in care notes, and the head injury was escalated promptly to the multi-disciplinary team.
Stated by Daryel Care
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Position
No inappropriate “No concerns” entry attributable to staff was found in the official electronic care records, so its origin and context cannot be confirmed.
Stated by Daryel Care -
Position
Daryel Care reported the fall to Adult Social Care, while ambulance attendance and hospital treatment had already addressed the immediate response.
Stated by London Borough of Islington
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Concerns raised1
Failure to clearly document medical advice obtained after resident 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 concernsEach 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.2
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Action
Prompt visiting healthcare professionals to sign in, accompany visits with senior staff, document advice and recommendations, and record information for handovers and audit.
Stated by Four Seasons Health Care Group -
Action
Deliver record-keeping, care-plan and documentation training covering contemporaneous entries, professional visits, emerging risks, RADAR records and archiving.
Stated by Four Seasons Health Care Group
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Concerns raised1
Lack of documentation demonstrating post-fall review of residents’ risk assessments
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 concernsEach 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.1
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Action
Require falls to be recorded and post-fall risk assessments completed within 24 hours, and communicate the requirement and its safety rationale to staff.
Stated by Management Team, Blenheim House Care Home
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Concerns raised1
Failure to record preceding resident falls in resident files
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.3
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Action
Conduct internal investigations of all falls, attach action plans, and report falls and incidents weekly to the Nominated Individual.
Stated by Cole Valley Nursing Home -
Action
Implement and maintain a centralized post-fall protocol folder containing guidance, a NEWS chart, and a timed observation log.
Stated by Cole Valley Nursing Home -
Action
Implement daily and nightly nursing handover reports, with daily managerial review and a Daily Walkabout Form recording recent incidents and resulting actions.
Stated by Cole Valley Nursing Home
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Concerns raised1
Failure to complete and update falls-related records
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 concernsEach 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.1
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Action
Review falls weekly in the PCS system, document actions, and update affected residents’ support plans.
Stated by Borough Care Ltd
Data last updated 7 September 2026