First reported 3 Sep 2014•Latest report 25 Feb 2026
Definition
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.
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
16
Distinct published reports
Individual concerns
18
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
34
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.
Aneurin Bevan University LHB1
Appleton Lodge1
Barchester Healthcare Limited1
Cole Valley Care Limited1
Derbyshire County Council1
East Kent Hospitals University NHS Foundation Trust1
East Surrey Hospital1
Fairfield View1
Hull University Teaching Hospitals NHS Trust1
Lodge Care Home1
Milford House Care Home1
NHS Derby and Derbyshire Integrated Care Board1
Northumbria Healthcare NHS Foundation Trust1
Royal London Hospital1
Royal Sussex County Hospital1
NHS trust6
Nursing home3
Healthcare site2
Multi-service care provider2
Private limited company2
Residential care home2
English county council1
English metropolitan district council1
Integrated care board1
Limited liability partnership1
Local health board1
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.
East Riding and Hull
Concerns raised2
Incomplete falls risk documentation
Failure to update falls risk assessments as required
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 concerns
Each 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.7
Action
Complete multidisciplinary post-fall debrief and SWARM review to identify systemic falls-prevention learning.
Stated by Humber Health PartnershipStated completedThe respondent said that this action was complete when they made their response on 2 March 2026.
Action
Introduce Ward 32 spot checks and leadership oversight of documentation and reassessment completion.
Stated by Humber Health PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 2 March 2026.
Action
Provide Falls Prevention Team educator support to Ward 32 staff on completing falls assessments and associated documentation.
Stated by Humber Health PartnershipStated plannedThe respondent said that this action was planned when they made their response on 2 March 2026.
Action
Conduct a specialist falls audit or accreditation review of Ward 32 to identify gaps, recommend improvements, and assess measurable progress.
Stated by Humber Health PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 2 March 2026.
Action
Monitor training, falls assessments, transfer reassessments, documentation, delirium assessment, post-fall reviews, and audit findings through local and group governance.
Stated by Humber Health PartnershipStated plannedThe respondent said that this action was planned when they made their response on 2 March 2026.
Action
Implement Ward 32 actions covering falls training, documented call-bell education, timely post-fall medical review, 4AT assessment, lying and standing blood pressure, transfer assessments, and AFLOAT checks.
Stated by Humber Health PartnershipStatus unclearThe respondent did not make the status of this action clear when they made their response on 2 March 2026.
Action
Reinforce reassessment of relevant clinical assessments when patients transfer between clinical areas across inpatient wards.
Stated by Humber Health PartnershipStated completedThe respondent said that this action was complete when they made their response on 2 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Falls risk had been recognised and multiple prevention measures were in place before the fall, despite shortcomings in transfer reassessment and documentation.
Stated by Humber Health PartnershipDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Yorkshire (Eastern)
Concerns raised1
Failure to document falls prevention measures at the first falls assessment
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Make falls-prevention documentation mandatory in risk assessments and audit compliance through Tendable.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Worcestershire
Concerns raised1
Failure to document falls prevention measures following falls risk assessments
Responses linked to these concerns
Each 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
Action
Review the electronic post-fall record and intervention document and clarify completion expectations.
Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 September 2024.
Action
Explore barriers to documenting falls interventions on the electronic patient record, take resulting actions and monitor them through the Improving Safety Action Group.
Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 September 2024.
Action
Distribute guidance on documenting falls interventions in Sunrise.
Stated by Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 September 2024.
County Durham and Darlington
Concerns raised1
Inadequate and inconsistent documentation of falls risk management
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 concerns
Each 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.7
Action
Review risk management plans and clarify documentation, review, updating and clinical-rationale expectations for staff.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
Action
Make falls-documentation compliance and quality a continuing review point in annual appraisals.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
Action
Review accident and incident reports to identify required responses and further falls-mitigation measures.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
Action
Discuss accidents and incidents in weekly clinical reviews and assign actions to update assessments and management plans.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
Action
Have the Deputy Manager review assessments and plans to triangulate care and verify completion of assigned clinical-review actions.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
Action
Audit high-risk patients’ assessments and management-plan documentation to verify appropriate assessment and recording.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
Action
Maintain improved falls-documentation standards through an ongoing audit programme.
Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 14 February 2024.
Worcestershire
Concerns raised1
Failure to update residents’ falls risk assessment and care plan documentation following falls
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 concerns
Each 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
Action
Amend monthly clinical governance meetings to review each resident’s falls and falls history.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 14 April 2023.
Action
Introduce a regional falls champion forum chaired by divisional clinical lead nurses.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 14 April 2023.
Action
Deliver refresher training at Latimer Court on completing documentation, including risk-related detail and timely updates.
Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 14 April 2023.
Action
Develop Latimer Court checklists or prompts with the Clinical Development Nurse in line with the Falls Management Policy.
Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 14 April 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The identified practice matters were unlikely to have affected the resident’s outcome.
Stated by Barchester Healthcare LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Dorset
Concerns raised1
Failure to complete and record falls risk assessments after falls
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 concerns
Each 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
Action
Upload the post-falls assessment tool to the electronic recording system for staff use and recording.
Stated by Tricuro LtdStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Action
Disseminate the updated falls policy across the service and wider company, including requirements to update risk assessments and mobility care plans after falls.
Stated by Tricuro LtdStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Newcastle Upon Tyne and North Tyneside
Concerns raised2
Failure to maintain observational charts for patients at risk of falls
Failure to document daily and post-change falls-risk reassessments
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 concerns
Each 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
Action
Implement a ward observation chart specifying enhanced-observation levels and required frequencies.
Stated by Northumbria Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 July 2021.
Action
Place the AFLOAT assessment and observation chart into the NerveCentre electronic care record, with mandatory daily registered-nurse review.
Stated by Northumbria Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 July 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing observation charts, safety huddles, AFLOAT use and planned electronic alerts sufficiently reduce the risk of similar incidents, making further PFD action disproportionate.
Stated by Northumbria Healthcare NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Gwent
Concerns raised1
Failure to complete falls risk assessments and documentation
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Birmingham and Solihull
Concerns raised1
Undated and unsigned falls risk management and assessment documents
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.
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
Action
Introduce and complete comprehensive Falls Risk Assessments for all residents, with monthly or condition-triggered recalculation.
Stated by Cole Valley Nursing HomeStated completedThe respondent said that this action was complete when they made their response on 26 May 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Implemented control measures are considered sufficient to resolve the identified falls, wheelchair restraint and investigation concerns.
Stated by Cole Valley Nursing HomeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Derby and Derbyshire
Concerns raised1
Failure to undertake basic and proper investigations of falls risk assessments
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 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.
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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.
