Recurring concern

Failure to reliably hand over fall information

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First reported 10 Dec 2015•Latest report 17 Feb 2025

Definition

What this concern includes

Includes failures to hand over accurate, complete and relevant information about a patient's or resident's fall to incoming care staff, clinicians, ambulance crews, emergency services or other responsible responders, including failure to identify the appropriate person responsible for the handover.

Not included

Excludes general clinical, shift or care handover failures where the information is not specifically about a fall.
Excludes failures to assess, treat, investigate or follow up a fall after accurate fall information has been handed over.
Excludes failures limited to recording a fall when the handover of fall information is otherwise reliable.
Excludes generic staffing, training or documentation deficiencies unless they directly cause failure to hand over fall information.

Reports: 4
Individual concerns: 6
Date range: 2015–2025
Stated actions: 8

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Bondcare1

Charing Healthcare Ltd1

Royal Free London NHS Foundation Trust1

Your Health Limited1

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.

17 Feb2025
Inner North London
Concerns raised1
1. Failure to communicate accurate clinical information between ward and medical staff
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement and embed SBAR communication education in ward inductions, junior-doctor induction, safety huddles, board rounds and medical discussions.
  Stated by Royal Free London NHS Foundation TrustStated planned
2. Action
  Introduce and operate an additional mid-shift safety huddle reviewing high-fall-risk patients and changes in condition.
  Stated by Royal Free London NHS Foundation TrustStated completed
AI-generated summary

Carl Edmond EASTMAN · 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

Carl Eastman was admitted to hospital after a fall at home and later suffered an unwitnessed fall on 28 July 2024 while in hospital. He sustained an irreversible brain bleed and died in hospital that evening as a direct result of the injury. Concerns included delays in CT scans after falls, widespread communication and record-keeping issues, failure to follow post-fall procedures, and possible wider skills or knowledge deficits among 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
Failure to communicate accurate clinical information between ward and medical staff
Wider context from the report
“2. There was evidence of what I considered to be ‘widespread communication issues’ in the care provided to Mr Eastman. These included: • When the on-call doctor attended to review Mr Eastman at approximately 02:45 on 28 July 2024, ward staff (incorrectly) told the doctor that nobody had fallen on the ward, which lead to the doctor leaving the ward without Mr Eastman having been reviewed. As the consultant geriatrician said in his evidence, communication between the ward staff and medical staff was not good. • The evidence revealed that there were deficiencies in basic record keeping. ”
Source location
Carl Edmond EASTMAN · 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
Implement and embed SBAR communication education in ward inductions, junior-doctor induction, safety huddles, board rounds and medical discussions.

Verbatim wording from the response
“It is acknowledged that discussions concerning the patient’s condition could have been more thorough and this failure to communicate effectively has been taken extremely seriously by the teams involved. Communication amongst the nursing and medical teams is of the highest priority to the Trust, and immediate actions have been taken following this safety event to improve key elements of the ward-based and wider hospital communication. It has been identified that the implementation and education of the Situation, Background, Assessment and Recommendation (SBAR) method of communication, will enable the multi-disciplinary teams to ensure effective and precise information sharing in critical safety events such as Mr. Eastman’s.”

Source location
Response from Royal Free London NHS Foundation Trust
Page 2 · response
Published 20 February 2025
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
Introduce and operate an additional mid-shift safety huddle reviewing high-fall-risk patients and changes in condition.

Verbatim wording from the response
“• Introduction of an additional mid-shift ward safety huddle on the ward to include a review of patients at high risk of falling, and any changes in a patient’s condition at all”

Source location
Response from Royal Free London NHS Foundation Trust
Page 2 · response
Published 20 February 2025
Open published response
17 Dec2019
Central and South East Kent
Concerns raised2
1. Failure to hand over fall histories to returning care staff
2. Failure to inform attending GPs of falls before clinical attendance
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 4
1. Action
  Conduct a comprehensive review of the handover system.
  Stated by Charing Dale LimitedStated in progress
2. Action
  Implement paper-based handover arrangements across all homes, including comprehensive sheets, senior sign-offs and ongoing monitoring.
  Stated by Charing Dale LimitedStated in progress
3. Action
  Share inquest learning and reinforce escalation, handover and related procedures through manager communications, team meetings and supervision.
  Stated by Charing Dale LimitedStated completed
1. Action
  Introduce a specific audit of the handover process.
  Stated by Charing Dale LimitedStated planned
Respondent positions 2
1. Position
  The errors were considered individual judgment calls rather than evidence of systemic failures in existing processes.
  Stated by Charing Dale LimitedDisputes the concern
1. Position
  The GP escalation process cannot be unilaterally changed because it is driven by national general-practice arrangements.
  Stated by Charing Dale LimitedUnable to act
AI-generated summary

Terence Ewart JAMES · 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

Terence Ewart JAMES, aged 85, was living in a residential home when he sustained an unwitnessed fall on 17 April 2019 and a further fall on 20 April, resulting in a neck of femur fracture. He underwent surgery but became delirious, did not thrive, and died in hospital on 14 May 2019. Concerns included failures to inform the GP of the first fall, hand over the fall history to care staff, and escalate pain and deterioration for further medical advice.

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 hand over fall histories to returning care staff
Wider context from the report
“(2) The history of the fall on 17th April was not handed over to care staff who had returned from leave on 20th April. ”
Source location
Terence Ewart JAMES · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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 inform attending GPs of falls before clinical attendance
Wider context from the report
“(1) The GP was due to attend Mr James on 17th April and was not informed of his fall prior to his attendance. He had bruising and abrasion to his head and was on anticoagulation medication. The GP examined him and found no apparent neurological symptoms or fracture. He advised that if there was any deterioration to seek further urgent advice. The GP evidence was that he would have advised that Mr James be taken to hospital. ”
Source location
Terence Ewart JAMES · 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
Conduct a comprehensive review of the handover system.

Verbatim wording from the response
“However, due to the concerns raised by the Coroner, we are conducting a full review of our handover system. For the time being, we have reverted back to the paper based system for handovers, across all of our homes as it is a visual tool that can be read straight away rather than having to find the appropriate tab on a system to read back in the notes. The system was put in place at Chippendayle Lodge immediately after the inquest on 11 December 2019. It was communicated to staff in internal meetings, and we are ensuring that all staff understand the importance of ensuring the handover forms are completed in full. This is being done through team meetings, which have taken place, for example, on 11 December 2019 and 13 December 2019.”

Source location
2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 3 · response
Published 31 December 2019
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
Implement paper-based handover arrangements across all homes, including comprehensive sheets, senior sign-offs and ongoing monitoring.

Verbatim wording from the response
“However, due to the concerns raised by the Coroner, we are conducting a full review of our handover system. For the time being, we have reverted back to the paper based system for handovers, across all of our homes as it is a visual tool that can be read straight away rather than having to find the appropriate tab on a system to read back in the notes. The system was put in place at Chippendayle Lodge immediately after the inquest on 11 December 2019. It was communicated to staff in internal meetings, and we are ensuring that all staff understand the importance of ensuring the handover forms are completed in full. This is being done through team meetings, which have taken place, for example, on 11 December 2019 and 13 December 2019.”

Source location
2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 3 · response
Published 31 December 2019
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
Share inquest learning and reinforce escalation, handover and related procedures through manager communications, team meetings and supervision.

Verbatim wording from the response
“A further staff meeting was held on Friday, 13 December 2019, and the manager shared the details of the inquest to ensure that all staff understood the importance of following the systems and protocols in place and to enforce expectations in this respect.”

Source location
2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 3 · response
Published 31 December 2019
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
Introduce a specific audit of the handover process.

Verbatim wording from the response
“As an organisation, we also conduct regular audits. We have a schedule in place in this respect. We are also in the process of introducing a specific audit relating to the handover process, and this will be in place from 29 January 2020, after the managers’ meeting, where it will be discussed. We have endeavoured to put robust systems in place to ensure that errors do not occur again. The above being said, we had in fact put a great deal of thought”

Source location
2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 4 · response
Published 31 December 2019
Open published response
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
The errors were considered individual judgment calls rather than evidence of systemic failures in existing processes.

Verbatim wording from the response
“into the processes in place before the inquest, and we do believe that where errors occurred, they were individual judgment calls, rather than systemic errors.”

Source location
2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 5 · response
Published 31 December 2019
Open published response
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
The GP escalation process cannot be unilaterally changed because it is driven by national general-practice arrangements.

Verbatim wording from the response
“their associated GP surgery. Furthermore, we are not able to unilaterally change this process, as it is driven by national GP arrangements.”

Source location
2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 2 · response
Published 31 December 2019
Open published response
9 Mar2017
Birmingham and Solihull
Concerns raised1
1. Failure to provide emergency services with the correct incident history from the witness
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.
AI-generated summary

Frederick Bevan · 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

Frederick Bevan died at a care centre on 4 October 2016 from a head injury following a fall at the home on 22 September 2016. The principal concern was that emergency services may not receive an accurate account of an incident when its history is not provided by the witness, potentially affecting treatment.

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 provide emergency services with the correct incident history from the witness
Wider context from the report
“I was satisfied that Mr. Bevan’s fall was witnessed by a carer████████ However, two paramedics who attended in response to the 999 call following the fall both gained the clear understanding that the fall was not witnessed, they described that there were 4 or 5 members of staff present and the scene appears to have been somewhat chaotic. The likely explanation for the paramedics misunderstanding is that a clear hand-over of the history of the incident was not provided by the witness████████, but rather the nurses who has responded to the emergency call ‘took over’. This was accepted as a potential explanation by the home manager Judy Williams, who informed me that the policy is that the lead nurse should give the incident history to the paramedics: my concern is that if the history is not provided by the witness (regardless of whether they are a carer or a nurse) there is a risk that the correct history will not be given to emergency services which in some cases could have a detrimental effect on treatment. ”
Source location
Frederick Bevan · Prevention of Future Deaths report
Page 1 · concerns
Open source report
10 Dec2015
Nottinghamshire
Concerns raised2
1. Failure to hand over falls
2. Lack of clarity about staff responsibilities for handing over, recording and reporting falls
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.
Actions described in response 2
1. Action
  Introduce a staff handover document recording daily responsibilities and identifying the senior person in charge.
  Stated by Your Health LimitedStated completed
2. Action
  Alter shift patterns to create overlap for a protected, paid handover.
  Stated by Your Health LimitedStated completed
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 hand over 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
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clarity about staff responsibilities for handing over, recording and reporting 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
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
Introduce a staff handover document recording daily responsibilities and identifying the senior person in charge.

Verbatim wording from the response
“The Company has noted that there was some confusion as to who had overall responsibility when 2 senior staff were on duty and we introduced a staff handover document in September 2015 (attached) to document the daily responsibilities of individual staff on duty, as well as clearly outlining who the senior staff on duty were, and who was ultimately in charge of running the home.”

Source location
Elsie-Brown-Response
Page 3 · response
Published 4 December 2015
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
Alter shift patterns to create overlap for a protected, paid handover.

Verbatim wording from the response
“The Company has always recognised the importance of handovers as part of the daily routine for operating a service that runs 24 hours a day, 365 days a year. We are keen to ensure that the handover is a protected part of the day and is not interrupted in any way. We have consulted with staff and altered their shift patterns with effect from 21st January 2015, to ensure that we have an overlap of shifts which allows for a paid handover to take place to relay information about the people we are provided care and support to. We feel this will formalise the current system and make our handover process more robust.”

Source location
Elsie-Brown-Response
Page 4 · response
Published 4 December 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to communicate accurate clinical information between ward and medical staff

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

Concerns raised2

Failure to hand over fall histories to returning care staff

Failure to inform attending GPs of falls before clinical attendance

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to provide emergency services with the correct incident history from the witness

Concerns raised2

Failure to hand over falls

Lack of clarity about staff responsibilities for handing over, recording and reporting falls

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

Actions described in response 2

Actions described in response 4

Respondent positions 2

Actions described in response 2