Recurring concern
Unreliable post-fall assessment and clinical response
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Request correctionFirst reported 3 Dec 2013•Latest report 30 Mar 2026
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
- Individual concerns
- 57
- Date range
- 2013–2026
- Stated actions
- 76
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 escalate falls for further assessment of safe home mobility
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.3
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Action
Reinforce escalation of concerns through appropriate referrals to professionals who can assess risks and recommend protective measures.
Stated by City of Doncaster Council -
Action
Establish the Home First Forum to inform domiciliary care providers about referral routes for concerns.
Stated by City of Doncaster Council -
Action
Hold further Home First Forum events quarterly to maintain referral guidance for domiciliary care providers.
Stated by City of Doncaster Council
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Relevant professionals, rather than social care staff, must assess risks and recommend or order aids and equipment.
Stated by City of Doncaster Council
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Position
A single fall would not ordinarily require a referral unless carers considered referral to be in the person’s best interests.
Stated by City of Doncaster Council
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Concerns raised1
Lack of a protocol for medication oversight after client falls
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 raised1
Unavailability of an out-of-hours local falls service or team
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 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
Implement area-wide options to further mitigate the risk of prolonged waits on the floor after a fall.
Stated by NHS Derby and Derbyshire Integrated Care Board
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
Proposed alternative out-of-hours responders cannot safely recover people with suspected hip fractures because they have only seated-lifter equipment; ambulance attendance remains necessary.
Stated by NHS Derby and Derbyshire Integrated Care Board
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Concerns raised1
Deficiencies in procedures for escalation or non-escalation after a fall and subsequent medical intervention
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 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
Review the falls protocol and maintain monthly falls audits, professional escalation, post-fall reviews, and 24–48-hour monitoring.
Stated by Credenhill Court Rest Home
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 existing falls protocol is considered effective, with concerns outside its parameters referred to appropriate health professionals.
Stated by Credenhill Court Rest Home
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Concerns raised1
Delays in treatment of elderly frail patients following a fall
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
Improve patient flow through hospitals.
Stated by NHS England -
Action
Speed up hospital discharges.
Stated by NHS England
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Concerns raised2
Lack of documentation demonstrating post-fall review of residents’ risk assessments
Delays in completing post-fall risk assessment reviews
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
Require falls to be recorded and post-fall risk assessments completed within 24 hours, and communicate the requirement and its safety rationale to staff.
Stated by Management Team, Blenheim House Care Home
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Concerns raised1
Failure to conduct imaging after a fall to establish injury
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 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 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 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
Review and update the falls protocol in line with current NICE guidance, directing staff to contact 999 or 111.
Stated by Hampshire County Council
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Concerns raised1
Failure to inform attending GPs of falls before clinical attendance
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The GP escalation process cannot be unilaterally changed because it is driven by national general-practice arrangements.
Stated by Charing Dale Limited
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Position
The errors were considered individual judgment calls rather than evidence of systemic failures in existing processes.
Stated by Charing Dale Limited
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Concerns raised1
Failure to seek clinical assessment for frail residents following falls
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 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.
Data last updated 7 September 2026