Recurring concern

Unreliable post-fall assessment and clinical response

First to latest report 3 Dec 2013 — 30 Mar 2026

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.

Reports and published responses 44 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Plymouth, Torbay & South Devon

    AI-generated summary

    Karen Lesley Peters · 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

    Karen Peters suffered a fall and head injury in hospital on 28 March 2013, subsequently developing an acute subdural haemorrhage and dying on 29 March 2013 after delays in transfer to neurosurgical care. Concerns included nursing staffing and agency staff deployment, handover quality, neurological observations and escalation, administration of contraindicated anticoagulation, availability of airway support, and delays and coordination issues affecting time-critical transfer.

    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 escalate care after deteriorating neurological observations

    Wider context from the report

    “4. Measuring and Recording GCS After her fall at 14:00 hours an entry was made in the medical record that Karen was to have a CT scan in the event that her levels of consciousness fell. At 20:00 hours Nurse P noted a 1 point reduction to 14. At midnight a further set of observations (performed by an unidentified nurse) noted a further reduction to 13. On neither occasion was Karen sent for a CT scan nor was her treatment otherwise escalated. ████████ accepted at Inquest the need for continued education and training. I would be pleased to hear from you of the outcome in this regard. ”

    Source location

    Karen Lesley Peters · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. London (East)

    AI-generated summary

    Roy Joseph Godfrey · 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

    Roy Joseph Godfrey, a 71-year-old resident of a residential care home, suffered an unwitnessed fall and head injury while taking long-term warfarin. He was later found unresponsive and died from a fatal subdural haematoma. Concerns included insufficient awareness of the bleeding risk associated with head injury and warfarin, inadequate overnight neurological checks and recording, and shortcomings in the care home's investigation documentation.

    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 of nursing staff to establish a fallen patient’s medical and medication history

    Wider context from the report

    “5. The Deputy Manager confirmed that the qualified member of staff who attended when Mr Godfrey sustained his fall should have been aware of the increased risk of bleeding as a result of the long term warfarin. She confirmed that he may not have had access to the medication chart. It is my view that a qualified member of the nursing staff who attends a patient who has suffered a fall should make themselves aware of both the patient’s medical history and medication history. ”

    Source location

    Roy Joseph Godfrey · Prevention of Future Deaths report
    Page 2 · 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 carry out directed neurological and physical observations after a fall

    Wider context from the report

    “2. The staff at the care home accepted the responsibility of Mr Godfrey’s care following the paramedic’s assessment. They agreed to observe Mr Godfrey during the night. The actual checks carried out by the staff were not in accordance with the direction given by the paramedic. The senior care worker confirmed that she did not examine the swelling or check for alertness. 3. The Deputy Manager who gave evidence at the inquest confirmed that the checks carried out by the staff were not in her view appropriate. She would have expected the pupils to have been checked and checks to ensure that the patient was alert and orientated. ”

    Source location

    Roy Joseph Godfrey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Oxfordshire

    AI-generated summary

    Peter Norman Nott · 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

    Peter Norman Nott, who had Parkinson's disease and was at very high risk of falls, experienced an unwitnessed fall at a nursing home on 2 September 2013 and died on 8 September 2013 from a subdural haemorrhage and Parkinson's disease. The concerns included that neurological observations after the fall were not undertaken beyond a simple visual examination and that inaccurate information about his consciousness was passed to paramedics.

    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 undertake neurological observations and further examination after a fall

    Wider context from the report

    “Although staff at the care home were attentive to Dr Norman Nott after his fall, and advice was sought from Dr Norman Nott’s GP, it was accepted in questioning that the trained staff should have undertaken neurological observations over and above a simple visual examination. The need to undertake further examination was heightened when the length of time Dr Norman Nott remained lying down (although conscious) and certainly as this time extended into the afternoon. ”

    Source location

    Peter Norman Nott · 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

    Review policies and procedures for managing residents after unwitnessed falls.

    Verbatim wording from the response

    “The organisation has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. This procedure will be cascaded to all clinical staff with instructions that should a resident fall and it is unwitnessed, then nursing staff or the person in charge of a residential home, should commence neurological observations. These will be recorded using the Glasgow Coma Scale and incorporated into a resident’s care plan.”

    Source location

    2014-0229-Response-by-Elizabeth-Finn-Homes
    Page 1 · response
    Published 28 February 2014

    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

    Cascade the unwitnessed-fall procedure and require neurological observations using the Glasgow Coma Scale, recorded in residents’ care plans.

    Verbatim wording from the response

    “The organisation has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. This procedure will be cascaded to all clinical staff with instructions that should a resident fall and it is unwitnessed, then nursing staff or the person in charge of a residential home, should commence neurological observations. These will be recorded using the Glasgow Coma Scale and incorporated into a resident’s care plan.”

    Source location

    2014-0229-Response-by-Elizabeth-Finn-Homes
    Page 1 · response
    Published 28 February 2014

    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

    Reinforce fall-response procedures through staff meetings, monitor individual training needs, and review head-injury-care competencies.

    Verbatim wording from the response

    “This procedure will be reinforced during staff meetings and any individual training needs will be monitored through the supervision, learning and development programme. Basic competencies for head injury care will be reviewed with all clinical staff and the person in charge of our residential home.”

    Source location

    2014-0229-Response-by-Elizabeth-Finn-Homes
    Page 1 · response
    Published 28 February 2014

    Open published response

  4. Inner North London

    AI-generated summary

    Agostino COSTA · 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

    Agostino Costa died after an accidental fall in hospital on 12 May 2013, which hastened death from terminal disease. The principal concerns were staff confusion about falls-risk classification and management, inadequate training for a junior doctor, limited sharing of the hospital root cause analysis, and non-mandatory attendance at falls-prevention seminars.

    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 ensure staff competence in managing patients after falls

    Wider context from the report

    “4. The junior doctor present did not know how to deal with a patient post fall on the ward, though he had dealt with patients in the emergency unit who had fallen in the community. He had not attended the hospital training seminar on falls. 5. The hospital root cause analysis was not shared with all relevant members of staff, though it was signed off at the beginning of August. Thus learning points from it were completely lost to some. I heard that a great deal of work is being done in your trust to attempt to prevent falls and appropriately to treat patients when falls have occurred, but attendance at one of the monthly seminars run by the lead doctor for falls is not mandatory for all staff. ”

    Source location

    Agostino COSTA · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026