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 raised2
Insufficient understanding that post-fall medical reviews must include review of current medications
Insufficient understanding of the post-falls protocol on the surgical ward
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.3
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Action
Redraft the post-fall assessment sticker to require consideration of low-dose prophylactic anticoagulants.
Stated by Gloucestershire Hospitals NHS Foundation Trust -
Action
Provide training and instructions to doctors and nursing staff on assessing and managing prophylactic anticoagulants after falls.
Stated by Gloucestershire Hospitals NHS Foundation Trust -
Action
Train Trust nursing staff in falls assessment, prevention, documentation and post-fall management, with mandatory and educational refreshers.
Stated by Gloucestershire Hospitals NHS Foundation Trust
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Concerns raised1
Unavailability of a home-based falls response service
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
Operate a 24/7 Home 1st Rapids service providing rapid triage, home attendance, assessment and escalation for acute falls.
Stated by NHS Central East Integrated Care Board
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
Existing commissioned services sufficiently replace the discontinued falls service, covering acute, preventative and non-urgent community fall needs.
Stated by NHS Central East Integrated Care Board
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Concerns raised2
Failure to communicate the significance of post-fall deterioration signs to patients’ interpreters or carers
Failure to provide timely CT scanning after falls in elderly patients taking blood-thinning medications
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
Log the concerns with the NICE guideline surveillance team for consideration in ongoing surveillance.
Stated by National Institute for Health and Care Excellence -
Action
Take the issues into account when the relevant guideline areas are next reviewed.
Stated by National Institute for Health and Care Excellence
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Existing VTE and head-injury guidelines appropriately reflect available evidence and do not require amendment at this time.
Stated by National Institute for Health and Care Excellence
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Concerns raised1
Failure to follow the falls protocol requiring immobilisation and medical attention after a painful fall
This report raised 7 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.3
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Action
Disseminate the falls protocol to staff and incorporate it into new-staff induction.
Stated by Care First Class (UK) Limited -
Action
Include the falls policy in recorded staff supervision to clarify responsibilities after a resident fall.
Stated by Care First Class (UK) Limited -
Action
Add the falls policy to staff-meeting agendas as a lessons-learned item.
Stated by Care First Class (UK) Limited
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
The Registered Provider is responsible for ensuring staff competence, training, and compliance with care plans, risk assessments, policies and procedures.
Stated by Care Quality Commission
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Concerns raised3
Failure to document observations after a fall
Failure to comply with escalation processes following a fall
Lack of understanding of reviews and required post-fall processes
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
Brief staff on documentation requirements and the falls procedure, including lessons from the identified failings.
Stated by Fairfield View Care Centre -
Action
Audit care plans and daily records daily and weekly for accurate risk assessments and fall documentation.
Stated by Fairfield View Care Centre
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Concerns raised1
Delays in immediate post-fall attendance, examination and basic observations
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.
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
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Action
Review CCTV footage to determine whether Basic Life Support and Immediate Life Support training requires organisational or individual changes.
Stated by Leicestershire Partnership NHS Trust -
Action
Implement clinical emergency drills with immediate reflection and feedback for participating staff.
Stated by Leicestershire Partnership NHS Trust -
Action
Schedule further experiential learning and practice-development training on person-centred responses to emergency medical situations.
Stated by Leicestershire Partnership NHS Trust
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Concerns raised1
Insufficient post-fall neurological observations before discharge
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.4
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Action
Reinforce the head-injury and falls-management pathway through face-to-face staff training.
Stated by Sandwell and West Birmingham Hospitals NHS Trust -
Action
Issue an internal Patient Safety Notice on neurological observations and linking inpatient falls with head-injury management.
Stated by Sandwell and West Birmingham Hospitals NHS Trust -
Action
Amend the inpatient falls policy to require post-incident monitoring and link emergency-department and ward standards.
Stated by Sandwell and West Birmingham Hospitals NHS Trust
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Action
Install the new electronic patient record to provide decision support and alerts reinforcing inpatient-falls and head-injury standards.
Stated by Sandwell and West Birmingham Hospitals 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
Existing head-injury and inpatient-falls policies meet NICE and NPSA standards and remain suitable for staff use.
Stated by Sandwell and West Birmingham Hospitals NHS Trust
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Concerns raised3
Failure to complete nursing sections of post-falls checklists
Failure to conduct required neurological observations after falls
Failure to ensure communication between doctors and primary nurses after falls
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 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
Deliver multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.
Stated by Barts Health NHS Trust -
Action
Hold four daily multidisciplinary safety handover meetings and use them to address communication between ward doctors, elderly-care and haematology teams.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to act upon vulnerability 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 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 escalate required clinical review after a fall
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.4
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Action
Launch and disseminate the Clinical Communication and Handover Policy with structured escalation and handover documentation.
Stated by Pennine Acute Hospitals NHS Trust -
Action
Conduct quarterly audits of compliance with the Clinical Communication and Handover Policy.
Stated by Pennine Acute Hospitals NHS Trust -
Action
Include learning about failures to obtain and escalate medical review in the Medical Division Lessons Learned Bulletin and disseminate it across wards and departments.
Stated by Pennine Acute Hospitals NHS Trust
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Action
Require nursing staff to escalate urgent medical reviews through the specified clinical escalation route and use the SBAR communication tool.
Stated by Pennine Acute Hospitals NHS Trust
Data last updated 7 September 2026