Recurring concern

Unreliable falls risk assessment tools

Pin Get email alerts Request correction

First reported 5 Mar 2014•Latest report 19 May 2023

Definition

What this concern includes

Includes failures in tools or formal assessment instruments specifically used to assess falls risk, including subjective or unclear scoring, outdated content, inconsistent interpretation and inadequate objective criteria; include the anchor's subjective Falls Risk Assessment Tool and comparable reports concerning outdated or unclear falls-risk tools.

Not included

  • Excludes failures to carry out a falls-risk assessment when the tool or its criteria were not themselves deficient.
  • Excludes failures to implement falls-prevention measures after a complete and reliable falls-risk assessment.
  • Excludes generic risk-assessment, documentation, staffing or training deficiencies that are not specifically tied to the reliability of a falls-risk assessment tool.
  • Excludes assessment tools for other hazards, including VTE, suicide, safeguarding or general patient risk, unless the assertion explicitly concerns falls-risk assessment.
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2014–2023

First to latest report issue date

Stated actions
2

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.

County Durham and Darlington NHS Foundation Trust1
Hc-One Limited1
Hylton View1
Tameside and Glossop Integrated Care NHS Foundation Trust1
University Hospitals Birmingham 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.

  1. Birmingham and Solihull

    AI-generated summary

    Norma Winifred BRUTON · 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

    Norma Winifred BRUTON was admitted to hospital with a pneumothorax and other lung conditions, suffered an unwitnessed fall while walking to the bathroom, and sustained a fractured neck of femur. Her condition deteriorated after surgery and she died in hospital; concerns related to falls-risk assessments not prompting staff to consider or document attachments such as chest drains and intravenous infusions, or their relevance to falls risk.

    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 the falls risk assessment document to prompt assessment of attachment relevance

    Wider context from the report

    “1. The Birmingham Heartlands Hospital falls risk assessment document does not prompt staff to consider or document the presence of attachments such as chest drains or intravenous infusions. 2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls. 3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment. ”

    Source location

    Norma Winifred BRUTON · Prevention of Future Deaths report
    Page 1 · 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 the falls risk assessment and identify required improvements to capture equipment-related mobility risks.

    Verbatim wording from the response

    “Updates to falls risk assessment document We have considered the concerns you have raised within your report to prevent future deaths and we are taking steps to add in a drop down menu, within the falls risk assessment, which will allow staff to select an appropriate option if a patient has any equipment, such as drains, in place. This will then also be recorded in the PHAF (Patient Handling Assessment Form) therefore attachments will be reflected in both risk assessments. This will further increase staff awareness of falls risk factors.”

    Source location

    Response from University Hospitals Birmingham NHS Foundation Trust
    Page 2 · response
    Published 19 May 2023

    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

    Add a PICS falls-assessment dropdown for equipment such as drains and record the selected information in the Patient Handling Assessment Form.

    Verbatim wording from the response

    “Updates to falls risk assessment document We have considered the concerns you have raised within your report to prevent future deaths and we are taking steps to add in a drop down menu, within the falls risk assessment, which will allow staff to select an appropriate option if a patient has any equipment, such as drains, in place. This will then also be recorded in the PHAF (Patient Handling Assessment Form) therefore attachments will be reflected in both risk assessments. This will further increase staff awareness of falls risk factors.”

    Source location

    Response from University Hospitals Birmingham NHS Foundation Trust
    Page 2 · response
    Published 19 May 2023

    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

    Manual handling and falls assessments need not automatically feed into each other because staff are expected to consider them together with other records.

    Verbatim wording from the response

    “The information recorded in the manual handling assessment has not been designed to automatically feed into the falls risk assessment as this was considered to be a duplication of the information in the patient record. The recommendation is that these assessments are looked at in combination not isolation.”

    Source location

    Response from University Hospitals Birmingham NHS Foundation Trust
    Page 2 · response
    Published 19 May 2023

    Open published response

  2. Manchester South

    AI-generated summary

    Mrs Doris Douthwaite · 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 Doris Douthwaite, who had vascular dementia and other complex medical conditions, suffered three falls at Greatwood House Residential Care Home over 11–13 February 2018. She sustained a hip fracture, developed bronchopneumonia and died at Willow Wood Hospice on 26 February 2018. Concerns included vulnerable residents being left unsupervised, an unclear falls assessment tool, and the absence of an investigation into Mrs Douthwaite’s falls.

    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

    Risk of Falls Assessment Tool failing to provide clear and consistent guidance

    Wider context from the report

    “2. The Risk of Falls Assessment Tool currently used across HC-One’s homes was demonstrated in court to be unclear and susceptible to different interpretations. When asked about it in the course of her evidence, HC-One’s Area Director was not aware as to whether or not this Assessment Tool had recently been benchmarked as against others used within the industry; ”

    Source location

    Mrs Doris Douthwaite · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Sunderland

    AI-generated summary

    Mrs Sheila Sullivan Ross (Sheila) · 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 Sheila Sullivan Ross died at Sunderland Royal Hospital on 12 November 2017 after an unwitnessed fall at a care home, sustaining bilateral pubic rami fractures and subsequently deteriorating with urinary sepsis. Concerns included an outdated falls risk assessment tool, limitations in the care home buzzer system that could prevent timely assistance, and poor communication with Sheila’s family.

    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

    Use of an outdated falls risk assessment tool

    Wider context from the report

    “(1) The falls risk assessment tool used by the Care Home staff appeared to be outdated, and the subsequent level of falls risk recorded by staff was not in keeping with the score generated by the assessment tool. ”

    Source location

    Mrs Sheila Sullivan Ross (Sheila) · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. County Durham and Darlington

    AI-generated summary

    Thomas Luke-Taylor · 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

    Thomas Luke-Taylor, who had suffered a stroke, fell from his bed while in the Stroke Rehabilitation Ward at Bishop Auckland General Hospital, sustained a head injury and subsequently died. Concerns were raised about incorrect falls-risk assessments, inadequate supervision of a student nurse, and whether certain patients such as stroke patients should be presumed to be at increased risk of falls unless there were good reasons otherwise.

    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

    Lack of a presumption of increased falls risk for certain classes of patients in falls risk assessments

    Wider context from the report

    “In evidence the Matron was asked whether it might be preferable for the falls risk assessment form to give a presumption that certain classes of patients (for example stroke patients) were at increased risk of falls and should be considered as such unless there were good reasons to the contrary. It was her view that this would not be good practice as each and every patient should be assessed on an individual basis. Whilst that is a laudable outlook it was put to her that if there had been such a presumption then the misclassification by the original staff nurse and by the student nurse might have been avoided and this could lead either in this case or in other cases to a potentially different outcome. The matron's view was that freedom of assessment was nevertheless best practice. I indicated my concern over this issue as to whether there should be a presumption in certain cases of an increased risk of falls and that consideration of this issue would be useful. ”

    Source location

    Thomas Luke-Taylor · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Nellie Travis · 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

    Nellie Travis was admitted to hospital for anaemia and fell while rising from her bed on 2 October 2013, breaking her hip. The report raised concerns that the hospital’s Falls Risk Assessment tool was completed by a non-Trust bank nurse, was highly subjective, and needed to be replaced by a more objective assessment tool.

    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

    Lack of an objectively assessed falls risk assessment tool

    Wider context from the report

    “During the course of the evidence I was told that there is a Falls Risk Assessment tool used by the hospital, but in this case it had been completed and assessed by a ‘bank nurse’ who was not an employee of the Trust. The evidence given by the senior member of the nursing staff was to the effect that the operation of the Falls Risk Assessment Tool is very subjective and depends upon an individual opinion of the nurse completing it as to how high the falls risk is shown to be. It was agreed that such a document is of very little use at all and that a more objectively assessed tool needs to be adopted. ”

    Source location

    Nellie Travis · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
Back to top

Data last updated 7 September 2026