Recurring concern

Unreliable documentation of falls-risk management

First to latest report 3 Sep 2014 — 25 Feb 2026

Reports that mention this concern
16
Times this concern has been raised
18
Stated actions linked to this concern
34

What this concern includes

Includes failures to record, update or preserve falls-risk assessments, reassessments, precautions, management decisions and the rationale for measures adopted or not adopted, including the anchor's poor recording of falls-risk management and comparable discrepant or incomplete falls-risk documentation.

What is not included
  • Excludes failures to assess falls risk where the assessment itself, rather than its documentation, is the only deficient control.
  • Excludes failures to implement falls-prevention measures after accurate falls-risk documentation is available.
  • Excludes generic clinical-record deficiencies without a material falls-risk management component.
  • Excludes recording of falls or post-fall clinical responses where the asserted unsafe condition is not documentation of falls-risk management.

Reports and published responses 16 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Central and South East Kent

    AI-generated summary

    Peter Blakeney KING · 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

    Peter Blakeney King was admitted to hospital with confusion, headache, fever and limb weakness, and later fell from his bed on 18 March 2017, sustaining fatal head injuries. The concerns included inadequate documentation and implementation of falls precautions, use of bed rails despite an assessment that they were not recommended, failure to provide an observable bed and crash mat, and failure to address falls risk at handover.

    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 document falls risk assessments and fall-prevention interventions

    Wider context from the report

    “(2) In respect of Mr King a falls risk assessment and precautions to minimise the risk of falls was not properly documented; interventions were not recorded and no referrals were made to either the falls team or physiotherapy. A bed rails risk assessment was completed which recorded that bed rails were not recommended but were in use at the time of the fall. ”

    Source location

    Peter Blakeney KING · 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

    Review the Falls Risk Assessment and Care Plan to align it explicitly with NICE falls-prevention guidance.

    Verbatim wording from the response

    “There are no published studies of falls risk prediction tools that predicted risk at greater than 70% sensitivity. The National Institute Health and Care Excellence (NICE) therefore concluded that all inpatients aged 65 and older ‘should have their care managed as if they are at risk of falling’ on the basis that these patients ‘often have newly acquired risk factors (such as acute illness, delirium, cardiovascular disease, impaired mobility, medication or syncope syndrome) and are exposed to unfamiliar surroundings, which puts them at increased risk of falling during their inpatient stay’.¹ The current falls policy and risk assessment tool reflect NICE guidance and we have focused on these areas specifically in order to action the factors that are known to reduce falls risk.”

    Source location

    2017-0414-Response-by-East-Kent-NHS-Trust
    Page 2 · response
    Published 27 February 2018

    Open published response

  2. Manchester South

    AI-generated summary

    Ivy Mitchell · 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

    Ivy Mitchell, a care home resident with a history of falls, fell on 29 December 2016 and later developed a subcapital fracture and pneumonia. She deteriorated and died on 26 January 2017; concerns included inaccurate falls-risk documentation, inadequate understanding of post-fall processes and observations, failure to escalate appropriately, and lack of understanding about referral to the community nutrition team.

    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

    Inaccurate falls-risk documentation

    Wider context from the report

    “1. The documentation relating to the falls risk was inaccurate. It did not refer to previous falls and did not reflect her mobility; ”

    Source location

    Ivy Mitchell · 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

    Audit documentation on service users’ falls and mobility.

    Verbatim wording from the response

    “I enclose my reply, in response to regulation 28 in the case of Mrs Ivy Mitchell. I have now audited all the documentation in relation to falls and mobility of all the service users. In relation to Mrs Mitchell, I accept that the documentation and risk assessments did not accurately reflect her falls or mobility, which has caused me great concern.”

    Source location

    2017-0453-Response-by-Fairfield-View-Care-Centre
    Page 1 · response
    Published 18 July 2017

    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

    Audit care plans and daily records daily and weekly for accurate risk assessments and fall documentation.

    Verbatim wording from the response

    “Senior staff attended the meeting ████████ held in relation to documentation and the falls procedure. Details of which, I enclose. This information has been cascaded down to staff, and the importance of completing all the relevant documentation was discussed at length. I have emphasised the failings in relation to Mrs Mitchell, and that we must ensure it does not happen again to any of the service users. I am now auditing all care plans and daily records on a daily and weekly basis, to ensure accuracy regarding risk assessments, and that documentation in the event of a fall is completed accurately and in a timely manner.”

    Source location

    2017-0453-Response-by-Fairfield-View-Care-Centre
    Page 1 · response
    Published 18 July 2017

    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 care-planning training covering accurate risk assessments, service-user needs, documentation and involvement in care planning.

    Verbatim wording from the response

    “Unit Managers, Deputies and Senior Care Staff are undertaking a course on care planning, this will commence in September of this year with Tameside College. This will include how to complete an accurate risk assessment as well as identifying the needs of the service user. This course will provide them with more knowledge about the importance of documentation and of the need to involve the service user, where there is capacity, or their relatives in all care planning activities.”

    Source location

    2017-0453-Response-by-Fairfield-View-Care-Centre
    Page 1 · response
    Published 18 July 2017

    Open published response

  3. Inner North London

    AI-generated summary

    Margaret Emily TUCK · 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

    Margaret Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

    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

    Inaccurate recording of walking aids in falls risk assessments

    Wider context from the report

    “1. Although a falls risk assessment was conducted upon Margaret Tuck’s admission to hospital, when it demonstrated an increased risk of falling no falls prevention care plan was drafted. And, whilst most of the preventative measures that would have been detailed on such a care plan were implemented in any event, Mrs Tuck was described on the risk assessment as having no walking aids. In fact, she had a Zimmer frame, and it was while reaching for this Zimmer frame that she fell on the acute admissions unit. ”

    Source location

    Margaret Emily TUCK · 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

    Implement falls-risk identification and prevention measures, including standardised assessment, high-risk wristbands, direct-observation bays and monthly falls-reduction monitoring.

    Verbatim wording from the response

    “1. The Hospital has undertaken a major piece of work to ensure vulnerable patients are identified and cared for, ensuring their risk of falling is minimised. A falls working group meets monthly, with each clinical area having to present their incidence of falls and work in progress around reduction of these incidents. On the AAU (representative of most clinical areas) all patients are assessed using the Trust falls assessment paperwork (which has been newly amalgamated into a nursing documentation admissions booklet), and any patient identified as a high risk, is then issued with a brightly coloured wrist band with the words ‘HIGH RISK OF FALLS’ printed on it. This signals to all staff, whether regular or agency, that this patient is at risk. All our high risk patients are now under within a bay that allows direct observation by nurses at the nurses’ station.”

    Source location

    2016-0273-Response-by-Barths-Health-NHS-Trust
    Page 3 · response
    Published 26 July 2016

    Open published response

  4. Manchester South

    AI-generated summary

    Maria Silkin · 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

    Maria Silkin fell at a care home on or about 2 September 2014, broke her hip, was taken to hospital a week later, underwent surgery, and subsequently developed pneumonia. The concerns were that her falls history was inaccurately recorded as showing no previous falls and that this contributed to a delay in taking her to hospital.

    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 accurately record previous falls in falls risk assessments

    Wider context from the report

    “1. During the course of the evidence the Care Home produced a document entitled “Falls Risk Assessment”. In part of that document it was indicated that the “falls history” showed there had been no previous falls whereas I had already heard evidence which was not challenged, to the effect that she had previously fallen numerous times. 2. Because of the above, the action to take her to hospital was, in my opinion, delayed. ”

    Source location

    Maria Silkin · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Brighton and Hove

    AI-generated summary

    Maureen Annette ELLETT · 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

    The report concerns the death of Maureen Annette ELLETT; the circumstances are referred to the Record of Inquest. Concerns included incomplete emergency department documentation and observations, inadequate clinical planning and review, staffing and fatigue issues, and shortcomings in ECG and observation procedures. The report states that the cumulative effect of these issues was considered catastrophic by the inquest.

    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 emergency department nursing documentation and falls assessment

    Wider context from the report

    “(4) The second Triage Nurse in A & E did the assessment on Mrs. Ellett at the end of a 12½ hour shift which was due to end at 20:00 hours on the 16th June, 2014. She saw Mrs. Ellett at approximately 19:20 hours and out of the two pages of emergency department Nursing Documentation which require over 80-pieces of information recorded, she recorded merely 12 pieces of information. The Falls Risk Assessment was completely blank and yet Mrs. Ellett was at high risk of falls and should have been provided with a green wrist band to alert all staff to this. It is thought that this shift is too long and at the end of it, staff who have had no proper breaks will be exhausted. It is considered that all staff should be trained on the importance of completing hospital documentation. ”

    Source location

    Maureen Annette ELLETT · 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

    Provide further documentation training through departmental nurse induction and nurse development training days.

    Verbatim wording from the response

    “4. We have established that the triage nurse to whom you refer handed over to her colleague starting the next shift that there were several outstanding assessments to be completed and documented for Mrs Ellett. We deeply regret that this next member of staff, who had newly come on duty, did not complete these tasks as he should have done. We have not been able to take this up with him in the light of your comments as he had already left the Trust before Mrs Ellett’s inquest took place. Arrangements have been made for further training on documentation to be included in both the departmental nurse induction programme and also in the nurse development training days held in the department.”

    Source location

    2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 31 October 2014

    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

    Conduct regular audits to ensure Short Stay Ward and Clinical Decisions Unit proformas are used correctly.

    Verbatim wording from the response

    “The nursing and medical staff in the Emergency Department, as well as the locum staff involved in the care of Mrs Ellett, and we ourselves have taken very seriously all the issues you have raised, and changes have been made to improve different aspects of the quality of care. As an over-arching step, individual named emergency consultants have recently been given responsibility for each of the Short Stay Ward and Clinical Decisions Unit, in order to provide visible senior medical leadership in each area and to seek ways of improving the quality of care. This will include regular audit to ensure proformas are being used correctly.”

    Source location

    2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 4 · response
    Published 31 October 2014

    Open published response

  6. Surrey

    AI-generated summary

    Hilda Florence Thompson · 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

    Hilda Florence Thompson, who had limited mobility and a history of falls, was admitted to hospital with breathlessness and later identified as a high falls risk. She collapsed on 19 January 2014, sustained an extensive intracranial injury, and died on 22 January 2014; concerns included an incomplete admission management plan, incorrect initial identification as not being at risk of falls, delayed falls assessment, and poor record-keeping.

    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

    Poor recording of falls-risk management

    Wider context from the report

    “• Upon her admission to hospital, her management plan was not completed and she was wrongly identified as not being a falls risk. • There was no further review of Mrs Thompson and it was not until 11/1/14 when a full falls risk assessment was made and preventable measures put into place. • Poor note taking of 2/1/14 to account for this. • This left a gap of some 10 days during which she was not properly risk assessed for falls. ”

    Source location

    Hilda Florence Thompson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026