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
-
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.
Linked response
- Rch Care Homes Limited
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
-
Rch Care Homes Limited
Instruct all staff not to move a person after a fall until a suitably trained person completes a full assessment.
-
Concerns raised1
Failure to establish whether a patient fall was unwitnessed and its force and details
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Haughton Thornley Medical Centres
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
-
Haughton Thornley Medical Centres
Record clear findings, admission or transfer rationale, fall circumstances, and responsibility for complete clinical notes.
-
Haughton Thornley Medical Centres
Undertake personal reading and clinical updates on assessing and managing falls.
-
Concerns raised1
Policy of treating a resident’s first fall as isolated without further action
This report raised 9 other concerns. 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.
-
Concerns raised1
Failure to regularly review fall-response training
This report raised 4 other concerns. 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.
-
Concerns raised1
Lack of a clear procedure for escalation and referral after a patient fall
This report raised 2 other concerns. 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.
-
Concerns raised1
Use of an out-of-date post-falls checklist lacking required neurological observation details
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- DRS GIBB MURCH GILLARD BOWYER & GEARY
- Royal Devon University Healthcare 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.2
-
Royal Devon University Healthcare NHS Foundation Trust
Revise and publish the falls policy and post-falls checklist to specify NICE-based neurological observation frequency and duration after suspected or confirmed head injury.
-
Royal Devon University Healthcare NHS Foundation Trust
Issue and disseminate a Trust-wide Patient Safety Alert covering neurological observations, post-falls checklist completion and filing, and inclusion of falls information in briefings and handovers.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
DRS GIBB MURCH GILLARD BOWYER & GEARY
The recommended safety actions are primarily the responsibility of the hospital trust.
-
DRS GIBB MURCH GILLARD BOWYER & GEARY
The hospital trust’s action plan is considered to satisfactorily address all concerns and recommended actions.
-
Concerns raised1
Failure to seek or consider medical attention following pain or a fall
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to record post-fall neurological observations
This report raised 5 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.5
-
Barts Health NHS Trust
Include documentation and falls management in induction for new medical trainees.
-
Barts Health NHS Trust
Hold twice-daily safety briefings highlighting the Trust falls protocol.
-
Barts Health NHS Trust
Remind nursing staff that the nurse in charge is responsible for following and documenting the correct falls procedure.
-
Barts Health NHS Trust
Provide nurses with neurological-observation training through the Critical Care Outreach Team.
-
Barts Health NHS Trust
Audit nurses’ falls-policy understanding, care-plan documentation, neurological-observation understanding, and competence in performing neurological observations.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Barts Health NHS Trust
Appropriate neurological observations were carried out after the fall; the missing chart was inadvertently misfiled.
-
Concerns raised1
Failure to make neurological observations after falls and facial injury
Linked response
- Cwm Taf Morgannwg University Local Health 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
-
Cwm Taf Morgannwg University Local Health Board
Implement compliance with neurological investigations following head injury.
-
Concerns raised1
Lack of a protocol for doctor examination of residents after more than one fall in a 24-hour period
Linked response
- Alexandra Rose Residential Care Home
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
-
Alexandra Rose Residential Care Home
Implement a falls-alert process notifying residents’ surgeries after repeated falls, using fax notification for the agreed practice and direct calls for other surgeries.
-
Alexandra Rose Residential Care Home
Add the falls-alert protocol to every resident’s care plan under mobility and falls-risk assessments.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026