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 raised1
Failure to escalate falls for further assessment of safe home mobility
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- City of Doncaster Council
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
-
City of Doncaster Council
Reinforce escalation of concerns through appropriate referrals to professionals who can assess risks and recommend protective measures.
-
City of Doncaster Council
Establish the Home First Forum to inform domiciliary care providers about referral routes for concerns.
-
City of Doncaster Council
Hold further Home First Forum events quarterly to maintain referral guidance for domiciliary care providers.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
City of Doncaster Council
Relevant professionals, rather than social care staff, must assess risks and recommend or order aids and equipment.
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City of Doncaster Council
A single fall would not ordinarily require a referral unless carers considered referral to be in the person’s best interests.
-
Concerns raised1
Lack of a protocol for medication oversight after client falls
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Unavailability of an out-of-hours local falls service or team
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- NHS Derby and Derbyshire 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 Derby and Derbyshire Integrated Care Board
Implement area-wide options to further mitigate the risk of prolonged waits on the floor after a fall.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
NHS Derby and Derbyshire Integrated Care Board
Proposed alternative out-of-hours responders cannot safely recover people with suspected hip fractures because they have only seated-lifter equipment; ambulance attendance remains necessary.
-
Concerns raised1
Deficiencies in procedures for escalation or non-escalation after a fall and subsequent medical intervention
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Credenhill Court Rest 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.1
-
Credenhill Court Rest Home
Review the falls protocol and maintain monthly falls audits, professional escalation, post-fall reviews, and 24–48-hour monitoring.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Credenhill Court Rest Home
The existing falls protocol is considered effective, with concerns outside its parameters referred to appropriate health professionals.
-
Concerns raised1
Delays in treatment of elderly frail patients following a fall
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- NHS England
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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NHS England
Improve patient flow through hospitals.
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NHS England
Speed up hospital discharges.
-
Concerns raised2
Lack of documentation demonstrating post-fall review of residents’ risk assessments
Delays in completing post-fall risk assessment reviews
Linked response
- Management Team, Blenheim House 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.1
-
Management Team, Blenheim House Care Home
Require falls to be recorded and post-fall risk assessments completed within 24 hours, and communicate the requirement and its safety rationale to staff.
-
Concerns raised1
Failure to conduct imaging after a fall to establish injury
This report raised 6 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 clear direction in the post-falls process on when to call 999/111 for possible or suspected head injury
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Hampshire County Council
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
-
Hampshire County Council
Review and update the falls protocol in line with current NICE guidance, directing staff to contact 999 or 111.
-
Concerns raised1
Failure to inform attending GPs of falls before clinical attendance
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Charing Dale Limited
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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Charing Dale Limited
The GP escalation process cannot be unilaterally changed because it is driven by national general-practice arrangements.
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Charing Dale Limited
The errors were considered individual judgment calls rather than evidence of systemic failures in existing processes.
-
Concerns raised1
Failure to seek clinical assessment for frail residents following falls
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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026