First reported 3 Dec 2013•Latest report 30 Mar 2026
Definition
What this concern includes
Includes failures of controls specifically dedicated to post-fall care, including immediate assessment, medication review, neurological observations, clinical direction, medical review, injury escalation, monitoring and handover following a patient fall.
Not included
Excludes pre-fall falls-risk assessment and prevention measures unless the report also identifies a post-fall assessment or response failure.
Excludes generic clinical review, escalation or documentation deficiencies not specifically connected to care after a patient fall.
Excludes delays in ambulance attendance or hospital admission where no post-fall clinical assessment or response deficiency is identified.
Excludes unrelated medication-review failures outside the post-fall care process.
Reports
44
Distinct published reports
Individual concerns
57
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
76
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 Commission4
Barts Health NHS Trust2
Royal London Hospital2
Whittington Health NHS Trust2
Alexandra Rose Residential Care Home1
Barchester Healthcare Limited1
Blenheim House1
Bourne House, Old Sarum1
Bupa Care Homes1
Bupa UK Provision1
Care4u Health Care Limited1
Care First Class (UK) Limited1
Charing Healthcare Ltd1
City of Doncaster Council1
County Durham and Darlington NHS Foundation Trust1
NHS trust17
Nursing home7
Healthcare site5
Private limited company5
Health and social care service regulator4
Multi-service care provider3
Residential care home3
Domiciliary care provider2
English metropolitan district council2
Executive non-departmental public body2
Integrated care board2
Care-home operator1
English county council1
English unitary authority1
Information rights regulator1
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.
Berkshire
Concerns raised1
Failure of the post-falls proforma to prompt consideration of anticoagulation reversal and urgency
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised2
Failure to reassess falls risk after a fall
Failure to review warfarin prescriptions after a 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 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.6
Action
Implement a multidisciplinary falls quality-improvement programme covering footwear, medication review and post-fall multidisciplinary review.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
Action
Introduce a mandatory post-fall care bundle and checklist requiring structured assessment, neurological observations, escalation triggers and clinical documentation.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
Action
Introduce an out-of-hours falls review protocol requiring the Duty Matron or Site Manager to review inpatient falls within two hours.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
Action
Audit post-fall neurological observations through divisional governance and provide multidisciplinary simulation training on recognition, escalation and immediate management.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
Action
Implement a mandatory post-inpatient-fall medical review bundle and standardised proforma covering neurological assessment, imaging, anticoagulation, medication review and senior escalation.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
Action
Share case learning through medical and nursing governance forums and reinforce it through simulation training on deterioration, imaging and anticoagulation safety.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Yorkshire (Eastern)
Concerns raised3
Lack of clear direction from the attending doctor following a fall
Lack of a clear plan for the frequency and duration of neurological observations following a fall
Failure to complete inpatient post-fall reviews
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.2
Action
Embed requirements for attending doctors to document individualised post-fall neurological observation plans covering frequency, duration, review and escalation criteria.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
Action
Deliver and reinforce multidisciplinary training on complete, contemporaneous clinical documentation, including post-fall records and neurological observations.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
Surrey
Concerns raised1
Delays in seeking medical advice following unwitnessed falls
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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.
South Yorkshire (Eastern)
Concerns raised1
Delays in medical review following an inpatient fall
This report raised 8 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.3
Action
Expand resident-doctor induction content on responding to deteriorating patients and prioritise overnight reviews for clinically deteriorating patients.
Stated by the Rotherham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 June 2025.
Action
Move towards employing two medical registrars on call overnight.
Stated by the Rotherham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 June 2025.
Action
Review national inpatient-falls audit data and share findings and improvement actions for qualifying injured inpatients.
Stated by the Rotherham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 June 2025.
Blackpool and the Fylde
Concerns raised2
Failure to conduct an appropriate post-fall injury assessment
Failure to record all post-fall observation scores
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.8
Action
Implement the EnabLE digital care-planning system for scheduled post-fall observations, alerts and point-of-care recording.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Deliver targeted training and supervision on post-fall documentation, escalation, observation recording and lessons learned from the incident.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Complete NEWS2, RESTORE and sepsis training and themed supervision for recognising deteriorating residents.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Review the falls policy with clinical staff and reinforce procedures for responding and escalating after falls.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Deliver moving-and-handling refresher training covering post-fall procedures and techniques to mitigate falls.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Provide documentation prompt sheets to support completion of post-fall records.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Continue EnabLE drop-in support, documentation audits and remote monitoring for adherence and learning needs.
Stated by Barchester Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025.
Action
Complete induction, including NEWS2 training, for three new bank nurses.
Stated by Barchester Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025.
Inner North London
Concerns raised2
Failure to record significant post-fall injuries in care notes
Failure to escalate significant post-fall injuries for medical review
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.3
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
Enhance digital photographic injury-upload capability, obtaining explicit client consent in accordance with policy, to supplement written care-note descriptions.
Stated by Daryel CareStated plannedThe respondent said that this action was planned 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.5
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
No inappropriate “No concerns” entry attributable to staff was found in the official electronic care records, so its origin and context cannot be confirmed.
Stated by Daryel CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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.
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.
Inner North London
Concerns raised1
Wider staff skills and knowledge deficit affecting post-fall care
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Provide falls-protocol and post-fall-management education through junior-doctor induction and ongoing nursing and medical team education.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 February 2025.
Action
Deliver regular falls-prevention simulation training, including protocol, post-fall management, documentation, escalation and prevention, to nursing and medical staff.
Stated by Royal Free London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 February 2025.
County Durham and Darlington
Concerns raised1
Failure to obtain timely medical advice after a resident fall
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.1
Action
Apply the Group Falls Policy and supporting flowcharts covering falls protocols, referrals, care planning, risk assessment and post-fall actions.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
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Includes failures of controls specifically dedicated to post-fall care, including immediate assessment, medication review, neurological observations, clinical direction, medical review, injury escalation, monitoring and handover following a patient fall.
