First reported 17 Nov 2014•Latest report 26 Jun 2026
Definition
What this concern includes
Includes failures to monitor progression, reassess, revise management, seek medical advice or provide a prompt clinical response when significant bruising, deterioration or other signs indicate an apparent fall, impact or head injury.
Not included
Skin changes or bruising with no apparent injury or material safety concern
Generic delays in medical review where no significant injury sign is identified
Treatment-quality failures after the injury has been adequately assessed and escalated
Incident-prevention controls before an injury occurs
Reports
21
Distinct published reports
Individual concerns
25
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
31
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.
Care Quality Commission5
Recipient name withheld3
National Institute for Health and Care Excellence2
Audlem Medical Practice1
Barts Health NHS Trust1
Borough Care Ltd1
Cardiff & Vale University LHB1
Care First Class (UK) Limited1
Castlehill Specialist Care Centre1
Community Disability Nurse1
Cwm Taf Morgannwg University Local Health Board1
Daryel Care1
Deerlands Residential Home1
Department of Health and Social Care1
Eldercare (UK) Limited1
NHS trust7
Type not available6
Health and social care service regulator5
Private limited company4
English metropolitan district council3
Executive non-departmental public body3
Healthcare site3
Residential care home2
Care-home operator1
Coronial office1
Domiciliary care provider1
English county council1
Health-system partnership1
Local authority service1
Local health board1
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.
East Riding and Hull
Concerns raised1
Failure to follow the falls policy for suspected head, neck, back or hip injury
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 concerns
Each 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.5
Action
Deliver additional training on assessing, managing, escalating and documenting witnessed and unwitnessed falls and injuries.
Stated by Westfield Residential HomeStated in progressThe respondent said that this action was in progress when they made their response on 2 September 2026.
Action
Hold the scheduled staff meeting and practical workshop on falls assessment, observation, escalation and documentation.
Stated by Westfield Residential HomeStated plannedThe respondent said that this action was planned when they made their response on 2 September 2026.
Action
Provide all staff with guidance notes on post-fall assessment, safe movement, emergency escalation, monitoring, documentation and reporting.
Stated by Westfield Residential HomeStated plannedThe respondent said that this action was planned when they made their response on 2 September 2026.
Action
Circulate the updated Falls policy to existing and new staff through the policies-of-the-month programme.
Stated by Westfield Residential HomeStated completedThe respondent said that this action was complete when they made their response on 2 September 2026.
Action
Conduct an unannounced inspection assessing record keeping, falls management and staff handover processes.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 2 September 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
No regulatory action is currently required because inspection found no ongoing risk issues relating to the concerns.
Stated by Care Quality CommissionNo action considered necessaryThe respondent said that no further action was needed.
Position
Inspection evidence identified no concerns with the home's management of falls for current service users.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Worcestershire
Concerns raised1
Failure to recognise post-fall deterioration and seek timely medical assessment
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 concerns
Each 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
Action
Developed an action plan addressing unwitnessed falls, medical attention, record keeping, auditing and staff training.
Stated by Green Range LimitedStated completedThe respondent said that this action was complete when they made their response on 3 July 2025.
Action
Provided fall prevention and management training to staff.
Stated by Green Range LimitedStated completedThe respondent said that this action was complete when they made their response on 3 July 2025.
Inner North London
Concerns raised1
Failure to escalate significant post-fall injuries for medical review
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 concerns
Each 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
Action
Deliver mandatory refresher training on falls, head-injury recognition, recording, and escalation protocols to all care staff.
Stated by Daryel CareStated completedThe respondent said that this action was complete when they made their response on 31 March 2025.
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 CareStated plannedThe respondent said that this action was planned when they made their response on 31 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
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 CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Clinical oversight, including decisions about post-discharge medical review, was understood to be led by the Rapid Response team within the multi-agency framework.
Stated by Daryel CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Prior hospital assessment, existing MDT escalation, no acute red flags, and imminent care handover supported continued observation without separate immediate medical re-escalation.
Stated by Daryel CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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 IslingtonDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Yorkshire (Western)
Concerns raised1
Failure to monitor the progression of resident injuries
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 concerns
Each 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
Action
Update admissions, falls prevention and risk-assessment policies to require timely assessment, injury monitoring and medical escalation.
Stated by SheffcareStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
Action
Roll out refresher training on pre-admission assessments, detailed care notes, falls documentation and escalation, using anonymised scenarios and monthly monitoring.
Stated by SheffcareStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
Surrey
Concerns raised1
Failure to distinguish persistent vomiting from initial post-injury vomiting
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Black Country
Concerns raised1
Failure to follow the policy requiring 999 calls after falls involving head injury
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 concerns
Each 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
Action
Continue making 111/999 calls after falls and call 999 whenever a resident prescribed Apixaban falls.
Stated by Castlehill Specialist Care CentreStated completedThe respondent said that this action was complete when they made their response on 4 May 2021.
Action
Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 4 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.
Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Hampshire, Portsmouth and Southampton
Concerns raised1
Lack of clear direction in the post-falls process on when to call 999/111 for possible or suspected head injury
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 concerns
Each 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
Action
Review and update the falls protocol in line with current NICE guidance, directing staff to contact 999 or 111.
Stated by Hampshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
Black Country
Concerns raised2
Delays in seeking medical review after head injury
Failure to provide and adjust neurological observations after head injury
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Sussex
Concerns raised2
NICE guidelines inadequately addressing slow intracranial bleeding after falls in elderly patients
Failure of care staff to recognise and respond to head injury in anticoagulated patients
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Conduct the ongoing surveillance review of the head injury guideline to determine whether it requires updating.
Stated by National Institute for Health and Care ExcellenceStated in progressThe respondent said that this action was in progress when they made their response on 23 August 2019.
Action
Publish the final surveillance review decision in September 2019.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
Action
Implement the falls-management policy, admission and post-fall risk assessments, and ongoing falls-risk tracking and review.
Stated by Shaw Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Action
Increase and maintain staff safety training, competency assessment, mandatory-training tracking and first-aider coverage on every shift.
Stated by Shaw Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
NICE guidelines do not apply to the organisation, so it will not undertake work to address their adequacy.
Stated by Shaw Healthcare LimitedOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Chief Executive of NICE is responsible for responding to concerns about the adequacy of NICE guidelines.
Stated by Shaw Healthcare LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing NICE head-injury guidance already applies to injuries caused by both direct and indirect trauma.
Stated by National Institute for Health and Care ExcellenceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Wales Central
Concerns raised1
Failure to provide rapid A&E review for head injury patients with reducing or fluctuating Glasgow Coma Scores
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 concerns
Each 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
Position
Health boards are responsible for ensuring identified changes and service changes, not the support service.
Stated by NHS Wales Shared Services Partnership Legal and Risk Services and the Welsh Risk Pool ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures to monitor progression, reassess, revise management, seek medical advice or provide a prompt clinical response when significant bruising, deterioration or other signs indicate an apparent fall, impact or head injury.
