Recurring concern

Unreliable post-fall assessment and clinical response

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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
Individual concerns: 57
Date range: 2013–2026
Stated actions: 76

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

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.

17 Apr2014
Plymouth, Torbay & South Devon
Concerns raised1
1. Failure to escalate care after deteriorating neurological observations
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
31 Mar2014
London (East)
Concerns raised2
1. Failure of nursing staff to establish a fallen patient’s medical and medication history
2. Failure to carry out directed neurological and physical observations after a fall
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.
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
28 Feb2014
Oxfordshire
Concerns raised1
1. Failure to undertake neurological observations and further examination after a fall
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review policies and procedures for managing residents after unwitnessed falls.
  Stated by Elizabeth Finn Homes LimitedStated completed
2. Action
  Cascade the unwitnessed-fall procedure and require neurological observations using the Glasgow Coma Scale, recorded in residents’ care plans.
  Stated by Elizabeth Finn Homes LimitedStated planned
3. Action
  Reinforce fall-response procedures through staff meetings, monitor individual training needs, and review head-injury-care competencies.
  Stated by Elizabeth Finn Homes LimitedStated planned
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
3 Dec2013
Inner North London
Concerns raised1
1. Failure to ensure staff competence in managing patients after 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.
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to escalate care after deteriorating neurological observations

Concerns raised2

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

Failure to carry out directed neurological and physical observations after a fall

Concerns raised1

Failure to undertake neurological observations and further examination after a fall

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

Concerns raised1

Failure to ensure staff competence in managing patients after falls

Actions described in response 3