Recurring concern

Unreliable documentation of falls and related clinical response

First to latest report 31 Oct 2013 — 26 Feb 2026

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.

Reports and published responses 20 reports

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

  1. South Wales Central

    AI-generated summary

    David Bassett COOPER · 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

    David Bassett Cooper was admitted to hospital after a serious head injury caused by a fall in the community and sustained nine further falls while being transferred between wards. He died from a subdural haematoma caused by the final fall on 5 March 2016. The concerns included inadequate handovers about falls risk, incomplete nursing records, a failure to see the overall pattern of falls, and shortcomings in arranging additional one-to-one nursing care.

    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

    Inaccurate and incomplete nursing notes and falls records

    Wider context from the report

    “2. The accuracy and completeness of nursing notes and records left much to be desired. For example, on Ward 21 when he fell three times, there was no entry made in the Falls Diary – a document which was supposed to act as a tool for nursing staff to assess whether there was a pattern to the numerous falls being sustained – save for the last fall on 5th March. This deprived staff of the opportunity to see the ‘whole picture’ and to take into consideration the eight falls which he had sustained up to that point. ”

    Source location

    David Bassett COOPER · Prevention of Future Deaths report
    Page 1 · 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

    Falls management is devolved to directly managed units, while the Falls Management Group retains scrutiny and performance-review functions.

    Verbatim wording from the response

    “The Health Board established a Falls Management Group in September 2015. This was a task and finish group that reviewed policies and training requirements in relation to falls management. The Health Board introduced the National Patient Safety Agency’s Risk Assessments and I enclose the Health Board’s Falls Policy and other supporting information for your review. The Falls Management Group last met in December 2016 and devolved falls management to the Directly Managed Units to ensure clinical orientation and responsibility.”

    Source location

    2016-0459-Response-by-University-Health-Board
    Page 1 · response
    Published 12 February 2017

    Open published response

  2. Inner North London

    AI-generated summary

    Margaret Emily TUCK · 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

    Margaret Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

    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 complete nursing sections of post-falls checklists

    Wider context from the report

    “3. After her fall, Mrs Tuck was seen by a junior doctor who examined her thoroughly and filled in the medical portion of the post falls checklist. However, the nursing aspect of this form was never completed. The FY1 had wanted a neurological observation to be undertaken in addition to the protocol neurological observations of every 30 minutes, but her note was not wholly clear, and could have been interpreted as seeking only one neurological observation in total. In fact, no neurological observations at all were conducted on the day that Mrs Tuck fell, nor the day after. The FY1 doctor had wanted to speak to the primary nurse before leaving the bedside, but had been unable to find her. The twin nursing failures of documentation and observation might have been avoided if such a conversation had been mandatory, and there had been a simple way of achieving this. ”

    Source location

    Margaret Emily TUCK · 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

    Deliver multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.

    Verbatim wording from the response

    “3. Our Nurse Educator has been instrumental in setting up and delivering a new multi-disciplinary training programme around important issues, that includes falls prevention awareness and post falls care. As part of the Band 7 role regular assessment during the shift of care planned and delivered, is undertaken. All of our medical staff, including FY1’s, are invited to participate. Falls prevention and awareness is also included in the FY1 mandatory education programme. With the increased presence of Band 6 and 7 nurses on each shift all the clinical staff now have a first contact who they can handover important issues to, even when the named nurse is not on the ward. There are now four multidisciplinary board / handover meetings per 24-hours and these are focussed around patient safety and handover.”

    Source location

    2016-0273-Response-by-Barths-Health-NHS-Trust
    Page 3 · response
    Published 26 July 2016

    Open published response

  3. Brighton and Hove

    AI-generated summary

    Christine Valerie STREET · 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

    Christine Valerie STREET was admitted to hospital with an aggressive brain tumour causing disorientation, confusion, left-sided weakness and a risk of falling. On 11 September 2015, she was found unattended on a toilet floor after an unwitnessed fall, sustaining a minor head injury that accelerated her deterioration and the timing of her death. The report raised concerns about incomplete documentation, failures to follow observation procedures, the use and training of bank staff, and flawed recognition and management of the dying patient.

    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 complete admission and fall documentation

    Wider context from the report

    “(1) Documentation with regard to the admission document (which was not completed) and the doctors pro forma to document the fall on the 11th September 2015 (was not completed). The lack of these documents did not affect the outcome, but it is bad practice that they were not completed and placed with Mrs. Street’s notes. ”

    Source location

    Christine Valerie STREET · 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

    Follow up poor documentation with nursing and medical staff.

    Verbatim wording from the response

    “I am aware that the quality of documentation for Mrs Street was poor in several respects and this has been followed up with both nursing and medical staff. The staff had recognised that Mrs Street was at high risk of falls, and had intended her to have constant attention knowing that she lacked capacity to comprehend her risk of falling as a result of the tumour. It appears that the ward nurses had mistakenly thought that the ‘care record for patient requiring specialising’, which was available as an appendix to the Trust’s ‘policy for the observation of adult patients with mental health problems’, was not intended for use when caring for a patient who was suffering not from a mental illness but from a specific neurological condition - in this instance, a brain tumour. Rapid action was taken when this came to light, to correct their understanding.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 10 May 2016

    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

    Remind staff through weekly communications to follow observation policy, use the one-to-one care pathway and document care comprehensively and contemporaneously.

    Verbatim wording from the response

    “It is particularly disappointing that Mrs Street was injured in a fall as this Trust has worked very hard indeed over several years to implement an active falls prevention programme. As a result the Trust has one of the lowest rates of inpatient falls of any acute Trust in the country. Nevertheless, in her weekly message to staff, the Chief Executive has”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 10 May 2016

    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

    Organise a monthly neurosurgical records audit to improve documentation quality.

    Verbatim wording from the response

    “In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 10 May 2016

    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

    Conduct senior-nurse records spot checks, remedy shortcomings and educate staff on improving records.

    Verbatim wording from the response

    “In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 10 May 2016

    Open published response

  4. Nottinghamshire

    AI-generated summary

    Elsie Marjorie Brown · 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

    Elsie Marjorie Brown fell from her bed at Langwith Lodge Residential Care Home on 23 March 2015, suffering fractures to her left humerus and right hip. She died in hospital on 5 April 2015 from bronchopneumonia and lobar pneumonia, which developed as a result of the fractures. Concerns included the absence of falls-risk and bed-rails assessments, an incomplete and unreviewed care plan, unclear responsibilities, inadequate recording and handovers, insufficient auditing, and potentially inadequate night staffing.

    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 record falls

    Wider context from the report

    “6. Mrs Brown’s fall on 23rd March 2013 was not handed over, nor recorded nor reported, and there was a lack of clarity amongst staff as to where responsibilities for these matters rested. ”

    Source location

    Elsie Marjorie Brown · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Birmingham and Solihull

    AI-generated summary

    Allan Richard Beasley · 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

    Allan Richard Beasley, who had vascular dementia, was admitted to a care home after he could no longer manage at home and experienced multiple falls. Following a further fall, he was diagnosed with cervical spine fractures, developed a chest infection, deteriorated and died. Concerns included inadequate falls-risk assessment, failures to record and escalate falls, inaccurate observation records, and incomplete monitoring and review.

    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 correctly record falls

    Wider context from the report

    “(1) Staff were unaware of the Home’s Falls Prevention Policy. This meant staff failed to correctly record falls and escalate to appropriate senior staff. ”

    Source location

    Allan Richard Beasley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester West

    AI-generated summary

    Emmeline Hampson · 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

    Emmeline Hampson died in hospital on 6 November 2014 after a fall at her nursing home caused a subdural haematoma and intracerebral bleeding. The concerns included repeated falls without review of her falls risk assessment or referral back to the Falls Service, inadequate procedures and record keeping, shortcomings in alarm audibility and differentiation, and insufficient training of agency staff.

    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

    Omissions in documentation and record keeping of falls and changes in residents’ condition

    Wider context from the report

    “iv. There were omissions in the documentation and record keeping at the Nursing Home particularly in relation to falls, and changes in Mrs Hampson’s condition, which were witnessed by members of her family on a daily basis. ”

    Source location

    Emmeline Hampson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. West Sussex

    AI-generated summary

    Stanley Bere · 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

    Stanley Bere, a resident of a nursing home, fell on 31 October 2011 and sustained a fractured ankle that was not identified until 8 November 2011. He later developed an infection and died on 4 June 2012; the inquest recorded congestive cardiac failure and bronchopneumonia, with the fractured ankle and subsequent infection contributing to his death. Concerns included incomplete Cardex records, inadequate follow-up of incident reports, and insufficient cross-referencing or monitoring of records, which meant his injuries were not identified promptly.

    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 properly complete Cardex records

    Wider context from the report

    “(1) There was evidence provided at the Inquest that showed that the Cardex system used at the home was not being properly completed. Dates, on occasions, appeared to be out of order and important information such where a patient had fallen was not being recorded. Family concerns also did not appear to always be recorded. ”

    Source location

    Stanley Bere · 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

    Strengthen incident reporting by recording and updating falls, accidents and near misses, with regular management auditing and follow-up.

    Verbatim wording from the response

    “We have tightened up our reporting systems, particularly ensuring all falls, accidents and "near misses" are recorded, and updating on any accident or incident. A more secure system of archiving has been introduced. We have also found a copy of a receipt we asked the coroner's officer to sign when taking the records, as she had no letter with her. I have enclosed a copy for your records. The home manager regularly checks that issues are recorded and followed up in his regular auditing of documents. Staff are aware of the consequences if they do not follow correct procedures. These improvements were put in place immediately following the inquest.”

    Source location

    2014-0339-Response-by-Older-Peoples-Services
    Page 1 · response
    Published 4 July 2014

    Open published response

  8. London (East)

    AI-generated summary

    Roy Joseph Godfrey · 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

    Roy Joseph Godfrey, a 71-year-old resident of a residential care home, suffered an unwitnessed fall and head injury while taking long-term warfarin. He was later found unresponsive and died from a fatal subdural haematoma. Concerns included insufficient awareness of the bleeding risk associated with head injury and warfarin, inadequate overnight neurological checks and recording, and shortcomings in the care home's investigation documentation.

    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 appropriately record post-fall checks in clinical records

    Wider context from the report

    “4. The Deputy Manager who gave evidence confirmed that the checks that were carried out on Mr Godfrey were not appropriately recorded in the clinical records. ”

    Source location

    Roy Joseph Godfrey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Liverpool

    AI-generated summary

    Charles Gavin BRADLEY · 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

    Charles Gavin Bradley fell unwitnessed in the Assessment Unit at Arrowe Park Hospital on 21 February 2013 and sustained head injuries that proved fatal. The investigation and inquest identified inadequate record-keeping and communications, including failures concerning his transfer and unclear recording of the fall.

    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

    Inadequate recording of patient falls

    Wider context from the report

    “During the investigation and inquest into Mr Bradley’s death it was found that the record-keeping and communications at Arrowe Park Hospital were inadequate, ineffective making them unsafe. This was evidenced by findings that though Leeds Teaching Hospital had effective records as to the arrangements for the transfer of Mr Bradley to Arrowe Park on the 21st February 2013, when Mr Bradley arrived at Arrowe Park they were not expecting him. This is likely to have caused added worry and stress to his rehabilitation plan. It is further evidenced by the inadequate recording of his fall on the 21st February 2013. From the evidence it was unclear as to whether it was witnessed or not, was it in a bathroom and if so why was there mention of a filing cabinet near he lay? In other cases the matters reported could result in fatalities. Documentation, recordkeeping and communications are core basic skills for all who work in healthcare. Neither the HEALTH aspect nor the CARE aspect of a health care service can be delivered without these basic skills. It would be helpful to see a cross Trust action plan with regard to the improving documentation, record-keeping and communication in the response to this report ”

    Source location

    Charles Gavin BRADLEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Inner North London

    AI-generated summary

    John William Wright · 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

    John William Wright, who had a history of paranoid schizophrenia and COPD, was admitted to hospital with pneumonia and suffered several falls, including a fall that caused a fractured spine and left humerus. He died on 15 April 2013 from recurrent chest infections; the inquest concluded that his death resulted from an accident. Concerns included the lack of investigation into the cause of the fall and uncertainty about whether all relevant staff were trained in falls protocols and recording requirements.

    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 make appropriate electronic records of falls

    Wider context from the report

    “1. There was no investigation of the cause or potential cause of the fall (whether there were any external factors involved – water on the floor, over-cleaning or any other high risk matter) so as to ensure that further falls could be prevented if necessary. Even if it transpired that the cause could not be determined, the fall should have been treated as a Serious Untoward Incident that warranted some kind of investigation. The North Middlesex University Hospital NHS Trust Serious Incident Policy defines as ‘serious’ an ‘Accident while in hospital’ and I consider that such a fall should be considered to be an accident. The policy then details actions that should be taken by staff dependent on the urgency of the incident and the evidence that I was given confirmed that the appropriate electronic records were not made following the incident. 2. It was not at all clear from the evidence whether the training on falls policy and the protocols related to the recording of witnessed falls extended to the doctors as well as nurses and it is clear that, as a fall may be witnessed by any staff member at a hospital, the proper protocols should at least be known even if access to electronic means of recording an incident is limited for reasons of confidentiality. ”

    Source location

    John William Wright · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

Back to top

Data last updated 7 September 2026