Recurring concern
Unreliable documentation of falls and related clinical response
- Reports that mention this concern
- 20
- Times this concern has been raised
- 20
- Stated actions linked to this concern
- 23
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 20 reports
See individual reports that have raised this concern, and the actions taken in response
-
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.
Linked responses
- Barts Health NHS Trust
- Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Barts Health NHS Trust
Introduce a mandatory post-fall care bundle and checklist requiring structured assessment, neurological observations, escalation triggers and clinical documentation.
-
Barts Health NHS Trust
Reinforce contemporaneous documentation and communication of inpatient falls and significant safety events during nursing and medical handovers.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.
-
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.
Linked response
- Premiere Health Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
-
Premiere Health Limited
Have managers immediately review incident forms for detail, completeness and clinical appropriateness.
-
Premiere Health Limited
Strengthen falls management and post-incident observation procedures for documenting falls, assessments and escalation reasoning.
-
Premiere Health Limited
Use mandatory post-fall observation charts for unwitnessed or potentially injurious falls.
-
Premiere Health Limited
Provide care staff refresher training in incident reporting and falls management.
-
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.
Linked response
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
There is no record or evidence that the patient experienced a fall during admission.
-
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
The Trust disputes that Mr Horton experienced a fall during admission, stating that no record or evidence of a fall exists.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked response
- the Rotherham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
the Rotherham NHS Foundation Trust
Add a mandatory discharge-summary question covering inpatient falls and other safety incidents, and monitor it during implementation.
-
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.
Linked responses
- Daryel Care
- London Borough of Islington
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Daryel Care
Deliver mandatory refresher training on falls, head-injury recognition, recording, and escalation protocols to all care staff.
-
Daryel Care
Enhance digital photographic injury-upload capability, obtaining explicit client consent in accordance with policy, to supplement written care-note descriptions.
-
Daryel Care
Update care-documentation guidance and training with structured prompts for detailed injury descriptions and recording the rationale for non-escalation after initial reporting.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
Daryel Care
The fall and developing injury were recorded in care notes, and the head injury was escalated promptly to the multi-disciplinary team.
-
Daryel Care
No inappropriate “No concerns” entry attributable to staff was found in the official electronic care records, so its origin and context cannot be confirmed.
-
London Borough of Islington
Daryel Care reported the fall to Adult Social Care, while ambulance attendance and hospital treatment had already addressed the immediate response.
-
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.
Linked response
- Four Seasons Health Care Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Four Seasons Health Care Group
Prompt visiting healthcare professionals to sign in, accompany visits with senior staff, document advice and recommendations, and record information for handovers and audit.
-
Four Seasons Health Care Group
Deliver record-keeping, care-plan and documentation training covering contemporaneous entries, professional visits, emerging risks, RADAR records and archiving.
-
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.
Linked response
- Management Team, Blenheim House Care Home
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Management Team, Blenheim House Care Home
Require falls to be recorded and post-fall risk assessments completed within 24 hours, and communicate the requirement and its safety rationale to staff.
-
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.
Linked response
- Cole Valley Nursing Home
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Cole Valley Nursing Home
Conduct internal investigations of all falls, attach action plans, and report falls and incidents weekly to the Nominated Individual.
-
Cole Valley Nursing Home
Implement and maintain a centralized post-fall protocol folder containing guidance, a NEWS chart, and a timed observation log.
-
Cole Valley Nursing Home
Implement daily and nightly nursing handover reports, with daily managerial review and a Daily Walkabout Form recording recent incidents and resulting actions.
-
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.
Linked response
- Borough Care Ltd
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Borough Care Ltd
Review falls weekly in the PCS system, document actions, and update affected residents’ support plans.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026