Recurring concern

Failure to reliably follow up accident reports to prevent recurrence

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First reported 30 Aug 2013•Latest report 17 Jun 2025

Definition

What this concern includes

Includes failures in the dedicated accident-reporting process involving completion, review, investigation, management action, identification of repeat-incident risks or implementation of preventive strategies, including the anchor's possible failure to act on accident report forms and the separate report's failure to complete and investigate an incident form.

Not included

Excludes generic incident investigation, governance or learning failures not specifically concerning accident reports or accident forms.
Excludes failures to implement safety actions where no accident-report follow-up process is identified.
Excludes clinical treatment, observation or care deficiencies that are not part of reporting or following up an accident.
Excludes the underlying accident or hazard itself when no deficiency in accident reporting or follow-up is identified.

Reports: 4
Individual concerns: 4
Date range: 2013–2025
Stated actions: 6

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.

Herries Lodge1

LNT Software1

Prime Life Limited1

Sunrise Care Home1

the Rotherham 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 Jun2025
South Yorkshire (Eastern)
Concerns raised1
1. Failure to complete a Datix report following an inpatient fall
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.
Actions described in response 1
1. Action
  Add incident-reporting prompts to the nurse-in-charge checklist to identify and escalate outstanding Datix reports.
  Stated by the Rotherham NHS Foundation TrustStated completed
AI-generated summary

Hazel Gambles · 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

Hazel Gambles was admitted to hospital after a fall at home and was later found to have sustained a brain bleed in an unwitnessed in-patient fall. She died on 27 January 2025, and the report states that the head injury more than minimally contributed to her death. The principal concerns were failures to complete and implement falls assessments and prevention measures, delay in medical review, inadequate communication with her family, failure to report and investigate the fall, and omission of the fall from the discharge letter.

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 complete a Datix report following an inpatient fall
Wider context from the report
“There are several areas of concern around failures in documentation and failures to follow Trust policy, namely: 1. Lying and standing Blood Pressure was not recorded on admission. 2. There was no documentation of any falls prevention measures at the time of the first falls assessment. 3. There is no evidence of falls prevention measures being put in place following the first falls assessment. 4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen. 5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed. 6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain. 7. No Datix report was done following the in-patient fall leading to a delay in investigation. 8. The in-patient fall is not mentioned on the Discharge letter. I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and record keeping. ”
Source location
Hazel Gambles · 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
Add incident-reporting prompts to the nurse-in-charge checklist to identify and escalate outstanding Datix reports.

Verbatim wording from the response
“The nurse in charge checklist now asks the question “has there been any incidents? Have these been recorded via Datix?”. This gives an opportunity for the senior team to consider whether there are any outstanding incident reports and if so, ensure that these are reported at the earliest opportunity.”

Source location
Response from Rotherham NHS Foundation Trust
Page 5 · response
Published 30 June 2025
Open published response
22 Feb2022
Birmingham and Solihull
Concerns raised1
1. Failure to complete incident forms
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Monitor documentation daily through management checks, record triangulation, spot checks and immediate corrective supervision where shortcomings are identified.
  Stated by PrimeLife LimitedStated in progress
2. Action
  Ensure nursing and care staff read and understand accident, incident and falls-management policies.
  Stated by PrimeLife LimitedStated completed
3. Action
  Deliver falls-management and head-injury training to nurses, covering observations, documentation, assessments, care planning and falls-risk reduction.
  Stated by PrimeLife LimitedStated planned
1. Action
  Provide nurses with incident-form completion training and supervision, including body mapping.
  Stated by PrimeLife LimitedStatus at response
2. Action
  Deliver safeguarding training covering reportable incidents, incident reporting and incident auditing, with regional oversight of timely external reporting.
  Stated by PrimeLife LimitedStated completed
Respondent positions 1
1. Position
  Training for the clinical lead cannot currently be completed because the clinical lead is on long-term sick leave.
  Stated by PrimeLife LimitedUnable to act
AI-generated summary

Dorothy Ann SPIBY · 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

Dorothy Ann Spiby, a nursing home resident with dementia, frailty and type 1 diabetes, suffered an unwitnessed fall in her bedroom on 22 October 2021. She sustained an eye-socket fracture and two rib fractures, developed pneumonia in hospital, and died on 28 October 2021. Concerns included unclear and undocumented accounts of the incident, no incident form, no investigation, and no evidence of learning to safeguard residents in future.

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 complete incident forms
Wider context from the report
“1. Tamworth Court Nursing Home staff reported to the hospital that Mrs Spiby became distressed and ran into collision with a wall when trying to leave her room, before falling to the floor. The origin of this account was unclear from the evidence. No record was made of the incident in the nursing records. 2. No incident form was completed. 3. No investigation of the accident or the circumstances giving rise to it was undertaken. 4. There was no evidence of a commitment to learning from this incident with a view to safeguarding residents in the future. ”
Source location
Dorothy Ann SPIBY · 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
Monitor documentation daily through management checks, record triangulation, spot checks and immediate corrective supervision where shortcomings are identified.

Verbatim wording from the response
“• Any shortcomings in documentation are addressed immediately by the home management team. Conversations with staff are formally recorded within supervisions and any disciplinary action taken, as necessary. Where there is non-compliance found the staff members will be given supervisions and learning sheets will be completed with them to encourage adherence to best practice. Actions in this regard were completed by 18.3.22 as planned.”

Source location
Response from Prime Life Ltd
Page 2 · response
Published 24 February 2022
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
Ensure nursing and care staff read and understand accident, incident and falls-management policies.

Verbatim wording from the response
“• All nursing and care staff to be aware of Prime Life Accident/Incident Policies and Management of Falls Policy- evidence to be left staff have read and understand these policies. Actions to be completed by 11.4.22 and timeframes met.”

Source location
Response from Prime Life Ltd
Page 2 · response
Published 24 February 2022
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
Deliver falls-management and head-injury training to nurses, covering observations, documentation, assessments, care planning and falls-risk reduction.

Verbatim wording from the response
“• Falls Management including Head Injury Training for all nurses. Training to be delivered by the nurse trainer/advisor and to include: Body Mapping, vital observations including Neuro-observations, RESTORE2(NEWS2), Accident/Incident forms, care plans, risk assessments, daily notes, communication record – MDT and reducing the risk of falls. Actions to be completed by 22.4.22 (slight amendment to the original action plan in place due to annual leave and sickness amongst the nursing team) with the exception of the clinical lead who is currently on long term sick.”

Source location
Response from Prime Life Ltd
Page 2 · response
Published 24 February 2022
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
Provide nurses with incident-form completion training and supervision, including body mapping.

Verbatim wording from the response
“• Nurses to have training/supervision in Incident Form completion including body mapping. Training and supervisions to be undertaken by nurse trainer/advisor and timeframes set to 15.4.22. This has been completed by all nurses with the exception of the clinical lead who is”

Source location
Response from Prime Life Ltd
Page 2 · response
Published 24 February 2022
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
Deliver safeguarding training covering reportable incidents, incident reporting and incident auditing, with regional oversight of timely external reporting.

Verbatim wording from the response
“• Safeguarding training has been delivered by the internal quality team, this included reportable incidents, incident reports and auditing of incidents. It is now the responsibility of the regional operations team to ensure that any reportable incidents are being sent through to the local authority and other interested parties without delay. The manager’s review of incident reports will be completed and overseen by the regional operational team. Training to be delivered by the providers Quality Matters Team. This initial action was completed by 25.3.22.”

Source location
Response from Prime Life Ltd
Page 3 · response
Published 24 February 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Training for the clinical lead cannot currently be completed because the clinical lead is on long-term sick leave.

Verbatim wording from the response
“• Falls Management including Head Injury Training for all nurses. Training to be delivered by the nurse trainer/advisor and to include: Body Mapping, vital observations including Neuro-observations, RESTORE2(NEWS2), Accident/Incident forms, care plans, risk assessments, daily notes, communication record – MDT and reducing the risk of falls. Actions to be completed by 22.4.22 (slight amendment to the original action plan in place due to annual leave and sickness amongst the nursing team) with the exception of the clinical lead who is currently on long term sick.”

Source location
Response from Prime Life Ltd
Page 2 · response
Published 24 February 2022
Open published response
26 Oct2015
Birmingham and Solihull
Concerns raised1
1. Failure of senior staff to correctly review falls incident forms
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 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

Allan Richard Beasley · 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

Allan Richard Beasley, who had vascular dementia, was admitted to a care home after he could no longer manage at home and experienced multiple falls. Following a further fall, he was diagnosed with cervical spine fractures, developed a chest infection, deteriorated and died. Concerns included inadequate falls-risk assessment, failures to record and escalate falls, inaccurate observation records, and incomplete monitoring and review.

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 senior staff to correctly review falls incident forms
Wider context from the report
“(8) The falls incident forms were not correctly reviewed by senior staff. ”
Source location
Allan Richard Beasley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Aug2013
South Yorkshire (Western)
Concerns raised1
1. Possible failure to act on accident reports through risk or repeat-incident prevention strategies
This report raised 10 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

Mrs May Gibson · 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

Mrs May Gibson sustained fatal injuries in a significant fall in her room at Herries Lodge Care Home on 21 March 2013. The report identified failures in assessment, care planning, falls risk management, preventative measures, and staff training and supervision; the inquest found that her death was contributed to by neglect.

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
Possible failure to act on accident reports through risk or repeat-incident prevention strategies
Wider context from the report
“8) whilst not explored at the inquest, it may be that no managerial action was taken on the accident report forms to ensure that they were properly followed up with risk or repeat incident prevention strategies identified; ”
Source location
Mrs May Gibson · 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 complete a Datix report following an inpatient 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.1

Concerns raised1

Failure to complete incident forms

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure of senior staff to correctly review falls incident forms

Concerns raised1

Possible failure to act on accident reports through risk or repeat-incident prevention strategies

Actions described in response 1

Actions described in response 5

Respondent positions 1