Recurring concern
Failure to assess and respond promptly to significant signs of injury
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Request correctionFirst reported 17 Nov 2014•Latest report 26 Jun 2026
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
- Individual concerns
- 25
- Date range
- 2014–2026
- Stated actions
- 31
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 undertake further imaging in borderline presentations of significant head 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 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
No further investigations were considered necessary because there were no clinical signs indicating a need at the time.
Stated by Recipient name withheld
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Concerns raised1
Failure to deal with significant bruising
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 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 raised3
Failure to obtain medical review after head injury
Failure to revise management when new signs emerge after head injury
Failure to obtain and repeat immediate general observations after head injury
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
Introduce a formal trust-wide policy for managing head injury in patients and staff.
Stated by Barts Health NHS Trust -
Action
Roll out new post-head-injury guidance and training across Royal London Hospital Older Peoples Service wards.
Stated by Barts Health NHS Trust -
Action
Extend the post-head-injury guidance and training rollout to other inpatient areas.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure of clinical decision support software to register head injuries
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.3
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Position
Existing head-injury questioning and NICE-consistent triage are considered sufficient to identify relevant risks and provide the appropriate emergency response.
Stated by NHS Pathways
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Position
The Trust cannot change NHS Pathways because it is designed and managed by NHS Digital.
Stated by South Central Ambulance Service NHS Foundation Trust -
Position
Responsibility for reviewing and changing NHS Pathways should be directed to NHS Digital.
Stated by South Central Ambulance Service NHS Foundation Trust
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Concerns raised1
Failure to seek medical or paramedic assistance when warranted by a person's condition
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.2
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Action
Integrate a pain-assessment profile into the client assessment process and review the revised process with the service committee.
Stated by Eldercare (UK) Limited -
Action
Redesign the investigation checklist with STOP alerts, defined sections, clearer larger formatting, and clarified second-responder accuracy checks.
Stated by Eldercare (UK) Limited
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Concerns raised1
Failure to follow the falls protocol requiring immobilisation and medical attention after a painful fall
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.3
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Action
Disseminate the falls protocol to staff and incorporate it into new-staff induction.
Stated by Care First Class (UK) Limited -
Action
Include the falls policy in recorded staff supervision to clarify responsibilities after a resident fall.
Stated by Care First Class (UK) Limited -
Action
Add the falls policy to staff-meeting agendas as a lessons-learned item.
Stated by Care First Class (UK) Limited
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
The Registered Provider is responsible for ensuring staff competence, training, and compliance with care plans, risk assessments, policies and procedures.
Stated by Care Quality Commission
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Concerns raised1
Failure to perform CT head scans after significant facial and head bruising
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.
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
Recheck head-injury and inpatient-falls policies against NICE and NPSA standards.
Stated by Sandwell and West Birmingham Hospitals NHS Trust -
Action
Install the new electronic patient record to provide decision support and alerts reinforcing inpatient-falls and head-injury standards.
Stated by Sandwell and West Birmingham Hospitals 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
Existing head-injury and inpatient-falls policies meet NICE and NPSA standards and remain suitable for staff use.
Stated by Sandwell and West Birmingham Hospitals NHS Trust
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Concerns raised1
Failure to consider intracranial bleeding when assessing new confusion after a fall
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
Discuss serious incidents and morbidity and mortality issues through governance meetings and disseminate learning points to the acute admissions team.
Stated by Barts Health NHS Trust
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Concerns raised1
Delays in arranging emergency hospital assessment and transport after suspected significant injury
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
Update risk management plans for residents prescribed anticoagulants to require calling 999 immediately after a fall, accident or injury.
Stated by Borough Care Ltd
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Concerns raised1
Failure to assess injuries after a significant uncontrolled fall before repositioning the patient
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
Instruct all staff not to move a person after a fall until a suitably trained person completes a full assessment.
Stated by Rch Care Homes Limited
Data last updated 7 September 2026