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 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.
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
Instruct all staff not to move a person after a fall until a suitably trained person completes a full assessment.
Stated by Rch Care Homes Limited
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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.
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
Record clear findings, admission or transfer rationale, fall circumstances, and responsibility for complete clinical notes.
Stated by Haughton Thornley Medical Centres -
Action
Undertake personal reading and clinical updates on assessing and managing falls.
Stated by Haughton Thornley Medical Centres
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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.
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
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.
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 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.
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
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.
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
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.
Stated by Royal Devon University Healthcare NHS Foundation Trust -
Action
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.
Stated by Royal Devon University Healthcare NHS Foundation Trust
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 recommended safety actions are primarily the responsibility of the hospital trust.
Stated by DRS GIBB MURCH GILLARD BOWYER & GEARY
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Position
The hospital trust’s action plan is considered to satisfactorily address all concerns and recommended actions.
Stated by DRS GIBB MURCH GILLARD BOWYER & GEARY
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Concerns raised1
Failure to seek or consider medical attention following pain or a fall
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
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.
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.5
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Action
Include documentation and falls management in induction for new medical trainees.
Stated by Barts Health NHS Trust -
Action
Hold twice-daily safety briefings highlighting the Trust falls protocol.
Stated by Barts Health NHS Trust -
Action
Remind nursing staff that the nurse in charge is responsible for following and documenting the correct falls procedure.
Stated by Barts Health NHS Trust
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Action
Provide nurses with neurological-observation training through the Critical Care Outreach Team.
Stated by Barts Health NHS Trust -
Action
Audit nurses’ falls-policy understanding, care-plan documentation, neurological-observation understanding, and competence in performing neurological observations.
Stated by Barts Health NHS Trust
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
Appropriate neurological observations were carried out after the fall; the missing chart was inadvertently misfiled.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to make neurological observations after falls and facial injury
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 compliance with neurological investigations following head injury.
Stated by Cwm Taf Morgannwg University Local Health Board
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Concerns raised1
Lack of a protocol for doctor examination of residents after more than one fall in a 24-hour period
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
Implement a falls-alert process notifying residents’ surgeries after repeated falls, using fax notification for the agreed practice and direct calls for other surgeries.
Stated by Alexandra Rose Residential Care Home -
Action
Add the falls-alert protocol to every resident’s care plan under mobility and falls-risk assessments.
Stated by Alexandra Rose Residential Care Home
Data last updated 7 September 2026