Recurring concern
Unreliable post-fall assessment and clinical response
- Reports that mention this concern
- 44
- Times this concern has been raised
- 57
- Stated actions linked to this concern
- 76
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 44 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised2
Insufficient understanding that post-fall medical reviews must include review of current medications
Insufficient understanding of the post-falls protocol on the surgical ward
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Gloucestershire Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Gloucestershire Hospitals NHS Foundation Trust
Redraft the post-fall assessment sticker to require consideration of low-dose prophylactic anticoagulants.
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Gloucestershire Hospitals NHS Foundation Trust
Provide training and instructions to doctors and nursing staff on assessing and managing prophylactic anticoagulants after falls.
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Gloucestershire Hospitals NHS Foundation Trust
Train Trust nursing staff in falls assessment, prevention, documentation and post-fall management, with mandatory and educational refreshers.
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Concerns raised1
Unavailability of a home-based falls response service
Linked response
- NHS Central East Integrated Care Board
Stated actions 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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NHS Central East Integrated Care Board
Operate a 24/7 Home 1st Rapids service providing rapid triage, home attendance, assessment and escalation for acute falls.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
NHS Central East Integrated Care Board
Existing commissioned services sufficiently replace the discontinued falls service, covering acute, preventative and non-urgent community fall needs.
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Concerns raised2
Failure to communicate the significance of post-fall deterioration signs to patients’ interpreters or carers
Failure to provide timely CT scanning after falls in elderly patients taking blood-thinning medications
Linked response
- National Institute for Health and Care Excellence
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
National Institute for Health and Care Excellence
Log the concerns with the NICE guideline surveillance team for consideration in ongoing surveillance.
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National Institute for Health and Care Excellence
Take the issues into account when the relevant guideline areas are next reviewed.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
National Institute for Health and Care Excellence
Existing VTE and head-injury guidelines appropriately reflect available evidence and do not require amendment at this time.
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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.
Linked responses
- Care First Class (UK) Limited
- Care Quality Commission
Stated actions 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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Care First Class (UK) Limited
Disseminate the falls protocol to staff and incorporate it into new-staff induction.
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Care First Class (UK) Limited
Include the falls policy in recorded staff supervision to clarify responsibilities after a resident fall.
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Care First Class (UK) Limited
Add the falls policy to staff-meeting agendas as a lessons-learned item.
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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Care Quality Commission
The Registered Provider is responsible for ensuring staff competence, training, and compliance with care plans, risk assessments, policies and procedures.
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Concerns raised3
Failure to document observations after a fall
Failure to comply with escalation processes following a fall
Lack of understanding of reviews and required post-fall processes
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Fairfield View Care Centre
Stated actions 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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Fairfield View Care Centre
Brief staff on documentation requirements and the falls procedure, including lessons from the identified failings.
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Fairfield View Care Centre
Audit care plans and daily records daily and weekly for accurate risk assessments and fall documentation.
-
Concerns raised1
Delays in immediate post-fall attendance, examination and basic observations
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Leicestershire Partnership NHS Trust
Stated actions 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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Leicestershire Partnership NHS Trust
Review CCTV footage to determine whether Basic Life Support and Immediate Life Support training requires organisational or individual changes.
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Leicestershire Partnership NHS Trust
Implement clinical emergency drills with immediate reflection and feedback for participating staff.
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Leicestershire Partnership NHS Trust
Schedule further experiential learning and practice-development training on person-centred responses to emergency medical situations.
-
Concerns raised1
Insufficient post-fall neurological observations before discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sandwell and West Birmingham Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Sandwell and West Birmingham Hospitals NHS Trust
Reinforce the head-injury and falls-management pathway through face-to-face staff training.
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Sandwell and West Birmingham Hospitals NHS Trust
Issue an internal Patient Safety Notice on neurological observations and linking inpatient falls with head-injury management.
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Sandwell and West Birmingham Hospitals NHS Trust
Amend the inpatient falls policy to require post-incident monitoring and link emergency-department and ward standards.
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Sandwell and West Birmingham Hospitals NHS Trust
Install the new electronic patient record to provide decision support and alerts reinforcing inpatient-falls and head-injury standards.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Sandwell and West Birmingham Hospitals NHS Trust
Existing head-injury and inpatient-falls policies meet NICE and NPSA standards and remain suitable for staff use.
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Concerns raised3
Failure to complete nursing sections of post-falls checklists
Failure to conduct required neurological observations after falls
Failure to ensure communication between doctors and primary nurses after falls
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Barts Health NHS Trust
Stated actions 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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Barts Health NHS Trust
Deliver multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.
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Barts Health NHS Trust
Hold four daily multidisciplinary safety handover meetings and use them to address communication between ward doctors, elderly-care and haematology teams.
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Concerns raised1
Failure to act upon vulnerability after a fall
This report raised 1 other concern. They are not shown here because they do not form part of this recurring 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
Failure to escalate required clinical review after a fall
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Pennine Acute Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Pennine Acute Hospitals NHS Trust
Launch and disseminate the Clinical Communication and Handover Policy with structured escalation and handover documentation.
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Pennine Acute Hospitals NHS Trust
Conduct quarterly audits of compliance with the Clinical Communication and Handover Policy.
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Pennine Acute Hospitals NHS Trust
Include learning about failures to obtain and escalate medical review in the Medical Division Lessons Learned Bulletin and disseminate it across wards and departments.
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Pennine Acute Hospitals NHS Trust
Require nursing staff to escalate urgent medical reviews through the specified clinical escalation route and use the SBAR communication tool.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026