Recurring concern
Unreliable documentation of falls and related clinical response
First 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
Inaccurate and incomplete nursing notes and falls records
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.1
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Position
Falls management is devolved to directly managed units, while the Falls Management Group retains scrutiny and performance-review functions.
Stated by Swansea Bay University Local Health Board
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Concerns raised1
Failure to complete nursing sections of post-falls checklists
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 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
Deliver multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to complete admission and fall documentation
This report raised 7 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
Follow up poor documentation with nursing and medical staff.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Remind staff through weekly communications to follow observation policy, use the one-to-one care pathway and document care comprehensively and contemporaneously.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Organise a monthly neurosurgical records audit to improve documentation quality.
Stated by University Hospitals Sussex NHS Foundation Trust
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Action
Conduct senior-nurse records spot checks, remedy shortcomings and educate staff on improving records.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to record falls
This report raised 14 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 correctly record falls
This report raised 9 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
Omissions in documentation and record keeping of falls and changes in residents’ condition
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.
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 properly complete Cardex 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.
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
Strengthen incident reporting by recording and updating falls, accidents and near misses, with regular management auditing and follow-up.
Stated by The Salvation Army
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Concerns raised1
Failure to appropriately record post-fall checks in clinical records
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Inadequate recording of patient falls
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.
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 make appropriate electronic records of falls
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.
Data last updated 7 September 2026