Recurring concern

Unreliable completion and verification of falls-risk assessments

First to latest report 10 Dec 2015 — 30 Mar 2026

Reports that mention this concern
11
Times this concern has been raised
13
Stated actions linked to this concern
8

What this concern includes

Includes failures in the dedicated falls-risk assessment process involving completion, countersigning, verification of the accuracy and meaning of recorded information, required professional sign-off, and related assurance that the assessment has been properly completed and validated.

What is not included
  • Excludes failures to consider particular patient-specific falls-risk factors where the assessment was otherwise completed and verified; those belong to the existing concern about incomplete consideration of relevant factors in falls risk assessments.
  • Excludes generic risk-assessment, documentation or staff-competence deficiencies unless they directly concern completion or verification of a falls-risk assessment.
  • Excludes failures to implement falls-prevention measures after a falls-risk assessment has been reliably completed and verified.
  • Excludes risk assessments for hazards other than falls unless the assertion explicitly concerns the same falls-risk assessment process.

Reports and published responses 11 reports

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

  1. Berkshire

    AI-generated summary

    John Albert TARRANT · 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

    John Albert Tarrant, aged 84, died at Wexham Park Hospital after an unwitnessed fall while an inpatient on 29 April 2025, sustaining a brain bleed that later became unsurvivable. The principal concerns were inaccurate falls risk assessments and insufficient awareness or prompting regarding the urgency of anticoagulation reversal after a fall.

    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 ensure accurate falls risk assessment data and outcomes

    Wider context from the report

    “1. Falls risk assessments. Only 2 falls risk assessments were carried out after Mr Tarrant arrived at the hospital. Both falls risk assessments used the Hester Davis scoring system but both had carried out based on incorrect data. The falls risk assessments both resulted in a low-risk outcome which was not correct. Mr Tarrant should have been graded as a moderate risk even prior to his fall. Some of the data entered into the risk assessment tool was objectively wrong. For example in the risk assessment carried out hours after his fall it stated that he had not fallen before. I heard that the Trust did not have a way of assessing and auditing the accuracy of these risk assessments. Whilst I found that the errors in this inquest did not contribute to Mr Tarrant’s death incorrect risk assessments can lead to inadequate falls mitigation measures being put in place and incorrect information being provided to staff. ”

    Source location

    John Albert TARRANT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 assessment and auditing of falls risk assessment accuracy

    Wider context from the report

    “1. Falls risk assessments. Only 2 falls risk assessments were carried out after Mr Tarrant arrived at the hospital. Both falls risk assessments used the Hester Davis scoring system but both had carried out based on incorrect data. The falls risk assessments both resulted in a low-risk outcome which was not correct. Mr Tarrant should have been graded as a moderate risk even prior to his fall. Some of the data entered into the risk assessment tool was objectively wrong. For example in the risk assessment carried out hours after his fall it stated that he had not fallen before. I heard that the Trust did not have a way of assessing and auditing the accuracy of these risk assessments. Whilst I found that the errors in this inquest did not contribute to Mr Tarrant’s death incorrect risk assessments can lead to inadequate falls mitigation measures being put in place and incorrect information being provided to staff. ”

    Source location

    John Albert TARRANT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Worcestershire

    AI-generated summary

    George Lawrence RITCHIE · 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

    George Ritchie suffered an unwitnessed fall at The Meadows Nursing Home, sustaining a fractured hip that was surgically fixed; he later died on 29 April 2025 after further treatment for infections and continued decline. Concerns included inadequate falls-risk assessments and care plans, insufficient oversight, and concerningly low night-time staffing levels at The Meadows Nursing Home, with potential risks to residents at other homes operated by Cardinal Healthcare.

    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 falls risk assessments and care plans properly

    Wider context from the report

    “Although The Meadows Nursing Home's former Care Home Manager and former Clinical Lead and Deputy Manager accepted in evidence that Mr. Ritchie was a high risk of falling, the falls risk assessments and care plans in place for him from December 2024 onwards were wholly inadequate. Not only were those documents not completed properly, but there was no system of checks and oversight in place to ensure that they were being completed properly. One of those who failed to complete the falls risk assessment correctly was the Clinical Lead and Deputy Manager. There was no system in place from above her to ensure that she was doing her job correctly. From January 2025 Cardinal Healthcare's newly appointed Operations Manager, with a wealth of experience as a Care Home manager herself, was meant to address the many concerns about the Meadows Nursing Home raised in recent CQC inspections. There was no evidence that she had ever attempted to put in place some sort of supervision or oversight at The Meadows Nursing Home to ensure that important documents like these, which played a key part in keeping residents safe, were completed properly. I am also concerned that there appears to have been no recognition by Cardinal Healthcare that night-time staffing levels at The Meadows Nursing Home at the material time were concerningly low, and required addressing. The Meadows Nursing Home may now have closed, but Cardinal Healthcare continues to operate other nursing homes in other parts of the country. I am concerned that if Cardinal Healthcare failed to put in place at The Meadows Nursing Home sufficient oversight to ensure documentation was being completed correctly, and failed to recognise and act upon low staffing levels, there will remain a risk that the lives of residents at their other nursing homes may be put at risk. ”

    Source location

    George Lawrence RITCHIE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. South Wales Central

    AI-generated summary

    Valerie HILL · 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

    Valerie HILL died from pneumonia following a fall that caused a periprosthetic femur fracture, with COPD and frailty of old age contributing. She had remained on the floor for over 14 hours awaiting an ambulance after falling at Ty Bargoed Care Home. The report raised concerns about the identification, documentation and mitigation of falls risks, staff training, completion and oversight of risk assessments, and ambulance handover and patient-flow systems.

    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 obtain Registered Healthcare Professional countersignatures on falls-risk assessment forms

    Wider context from the report

    “(4) The exhibits to your statement at KL 1 page 58 appear to suggest that the risk assessment forms ought to be completed/counter-signed by a Registered Healthcare Professional. I received no evidence that such a practice was/is in operation at Ty Bargoed ”

    Source location

    Valerie HILL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Registered healthcare professional sign-off is inappropriate in local-authority care homes because such professionals are not routinely available and the requirement is context-specific.

    Verbatim wording from the response

    “17. Firstly, at paragraph (4) HM Senior Coroner identified that the risk assessment forms – according to the All Wales NHS Scheme documentation provided in my initial statement – required to be signed off by a Registered Healthcare Professional. It will be understood by HM Coroner that this documentation was developed, primarily, by the NHS in Wales for use in NHS settings, with regard to the moving and handling of NHS patients. The availability of Registered Healthcare Professionals in those settings is obvious. In a local authority residential care home environment, registered medical healthcare professionals of this type are never routinely available and the “requirement” for sign off of risk assessments by such persons is actually a vestige from the original environment in which these documents were developed (see above).”

    Source location

    Response from Merthyr Tydfil County Borough Council
    Page 5 · response
    Published 30 June 2025

    Open published response

  4. Dorset

    AI-generated summary

    Gerald Kenneth 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

    Gerald Kenneth Tuck, who had dementia and lived in a residential home, sustained repeated falls in December 2021 and January 2022. After the final fall, he was diagnosed with two acute subdural haematomas, his condition deteriorated, and he died on 2 March 2022. The concern was that the home had no written policy or guidance requiring care plans and falls risk assessments to be reviewed after incidents.

    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 and record falls risk assessments after falls

    Wider context from the report

    “iv. The Registered Manager of Sidney Gale House gave evidence that his last falls risk assessment is documented to have taken place on the 16th December 2021. There is no evidence one was completed after this prior to the fatal fall on the 28th January 2022. The monthly review was due on the 31st January 2022 and there was no assessment recorded after the falls on the 25th December 2021 and 27th January 2022. ”

    Source location

    Gerald Kenneth 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

    Upload the post-falls assessment tool to the electronic recording system for staff use and recording.

    Verbatim wording from the response

    “To mitigate further risks we have uploaded the post falls assessment tool to the electronic recording system that is used to ensure staff do see, follow and record on this.”

    Source location

    Response from Tricuro
    Page 2 · response
    Published 3 October 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

    Disseminate the updated falls policy across the service and wider company, including requirements to update risk assessments and mobility care plans after falls.

    Verbatim wording from the response

    “Our policy also reflects that staff are expected to update the falls risk assessments and mobility care plans after any fall to ensure that the care, support and risks are managed accordingly. We have ensured that all staff within the service and the wider company are very clear of the policy and that this must be followed.”

    Source location

    Response from Tricuro
    Page 3 · response
    Published 3 October 2022

    Open published response

  5. Gwent

    AI-generated summary

    Marvin John RUE · 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

    Marvin Rue was admitted to hospital on 8 January 2021 after a fall and fell five times during his admission. On 2 February 2021, he suffered a fatal head injury after another fall and died on 3 February 2021. The principal concerns were failures to complete falls-risk assessments after admission, hospital transfers and previous falls, resulting in inadequate supervision; the report also identified failures to investigate staff non-compliance and to carry out audits.

    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 regular ward audits of falls risk assessments

    Wider context from the report

    “Marvin Rue had fallen prior to his admission to hospital on 8th January 2021 and was therefore, due to his age and circumstances, a “known falls risk”. In evidence I heard that in these circumstances a Multifactorial Risk Assessment (MFRA) should take place within 6 hours of admission to hospital. It was not. Mr Rue was transferred between hospitals during his admission, initially to Nevill Hall Hospital and then to Ysbyty Aneurin Bevan. I heard in evidence that a review of the MFRA should take place after every hospital transfer. Mr Rue had no MFRA undertaken after his transfers. Mr Rue fell 5 times prior to his fatal fall in hospital on 2nd February 2021. Contrary to Health Board Policy, Mr Rue did not have an MFRA undertaken after any of these falls. In fact there was never an MFRA correctly completed for Mr Rue throughout his hospital admission. I heard evidence that during this time the staff were under significant pressure due to the effects of the pandemic, and I accept that. However the care that Mr Rue was denied was basic nursing care. ████████ the Lead Nurse and author of the Serious Concerns Report, indicated that had Mr Rue been assessed, he would have warranted 1:1 supervision . As a result I concluded that the failures in care directly contributed to Mr Rue’s death. During the inquest I have been presented with an action plan, however this is not the first action plan I have been presented with (in very similar circumstances) and sadly I am not convinced that this plan will prevent future deaths for the following reasons. The policies referred to above have been in place for several years. I am informed that although there is bespoke documentation training, all staff are trained in falls risk assessment from the time they are in nurse training. Therefore it is not a lack of understanding or policies which have caused these failures. None of the staff were interviewed during the internal investigation and no evidence was forthcoming as to why staff did not follow the procedures. Without this information I do not consider that the actions plan will prevent future deaths. I refer you to your previous responses to PFDs which have clearly not had the desired outcome. Despite being previously reassured that regular ward audits would take place to ensure that the risk assessment were being undertaken I heard no evidence that audits were completed at this time and so the failures went unnoticed until after Mr Rue’s death. ”

    Source location

    Marvin John RUE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Birmingham and Solihull

    AI-generated summary

    Jean Mary Cutler · 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

    Jean Mary Cutler had severe dementia, osteoporosis and no independent mobility, and was at high risk of falling. On 5 October 2018 she fell from her wheelchair at Cole Valley Nursing Home, sustaining a fractured left femur, and died there on 18 October 2018. Concerns included inconsistent use of lap belts, reliance on staff intervention despite understaffing, and inadequate post-incident investigation and falls risk assessment.

    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

    Undated and unsigned falls risk management and assessment documents

    Wider context from the report

    “6. The current falls Risk Management and Risk Assessment documents (requested by the CQC and CCG) are undated and unsigned and continue to place reliance on the presence of a staff member to prevent falls. My on-going concern is that the falls risk assessment has not being adequately completed. ”

    Source location

    Jean Mary Cutler · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate completion of falls risk assessments

    Wider context from the report

    “6. The current falls Risk Management and Risk Assessment documents (requested by the CQC and CCG) are undated and unsigned and continue to place reliance on the presence of a staff member to prevent falls. My on-going concern is that the falls risk assessment has not being adequately completed. ”

    Source location

    Jean Mary Cutler · 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

    Introduce and complete comprehensive Falls Risk Assessments for all residents, with monthly or condition-triggered recalculation.

    Verbatim wording from the response

    “ii) New, comprehensive Falls Risk Assessments (FRAs) for all residents have been introduced and completed. The FRAs consider internal and external risk factors, provide a risk score which then generates a “Low”, “Medium” or “High” risk rating (colour-coded Green, Amber or Red) and incorporate suggestions for risk management dependent on the level of risk identified. Risks will be recalculated on a (minimum) monthly basis (but sooner should an individual’s condition change i.e. through the contraction of an acute infection). Initial FRAs for people living in the Home were completed 03rd April 2019.”

    Source location

    2019-0040-Response-by-Cole-Valley-Nursing-Home
    Page 2 · response
    Published 26 May 2019

    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

    Implemented control measures are considered sufficient to resolve the identified falls, wheelchair restraint and investigation concerns.

    Verbatim wording from the response

    “Cole Valley Nursing Home and its Directors accept and acknowledge the Coroner’s Concerns and believe that the control measures implemented by the Home serves to demonstrate how the Home and Cole Valley Care Ltd. have resolved said concerns - learning from both the inquest and the concerns detailed within your Regulation 28 report.”

    Source location

    2019-0040-Response-by-Cole-Valley-Nursing-Home
    Page 3 · response
    Published 26 May 2019

    Open published response

  7. Manchester North

    AI-generated summary

    Beryl Ann Walsh · 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

    Beryl Ann Walsh sustained catastrophic head injuries in an unwitnessed fall from her bed at Beechwood Lodge Care Home on 3 June 2018, which led directly to her death. The principal concerns were missed opportunities to identify her as being at high risk of falls, refer her to the falls team, provide falls-prevention equipment, and undertake falls-risk assessments and care plans.

    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 undertake falls risk assessments

    Wider context from the report

    “1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home. During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken ”

    Source location

    Beryl Ann Walsh · 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

    Strengthen risk assessments for residents who have experienced falls.

    Verbatim wording from the response

    “1. We have put more in robust risk assessments for residents who have had falls.”

    Source location

    2018-0359-Response-by-Beechwood-Lodge
    Page 1 · response
    Published 25 April 2019

    Open published response

  8. Central and South East Kent

    AI-generated summary

    Harold Graham WONFOR · 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

    Harold Graham Wonfor was admitted to hospital with confusion, reduced mobility and a history of falls, but no falls assessment or prevention measures were put in place before he suffered an unwitnessed fall and head injury. He sustained a subdural haematoma, declined and died on 30 January 2017. The principal concerns were inadequate falls-risk assessment for vulnerable patients and inadequate monitoring and enforcement of falls-prevention policies and procedures.

    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 and review adequate falls risk assessments

    Wider context from the report

    “(1) Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William Harvey Hospital. Common to each was the fact that the death was caused as a result of a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced. Inquests in respect of each of the deaths have been held, the last in November 2017. The Trust was given an opportunity following the earlier inquests to provide evidence of changes to practice following the deaths. It is recognised that at the time of hearing the inquests much work has already been done to address these issues but that work is ongoing and parts of that work have not yet been implemented/were in the process of being implemented. It is for this reason that Regulation 28 reports arise from three of the deaths. ”

    Source location

    Harold Graham WONFOR · 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

    Continue timely and adequate falls risk assessments for patients.

    Verbatim wording from the response

    “We note this Regulation 28 Report to prevent future deaths is one of three Inquests heard by the Central and South East Coroners in September 2017 and the matters of concern relate to the management of falls within the Trust. Acknowledgement by the Senior Coroner of the improvements that have already been made by the Trust regarding timely and adequate falls risk assessments is gratefully received and this work continues as outlined in my response.”

    Source location

    2017-0408-Response-East-Kent-NHS-Trust
    Page 1 · response
    Published 26 February 2018

    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

    Review the Falls Risk Assessment and Care Plan to explicitly incorporate relevant 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’. 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

    2017-0408-Response-East-Kent-NHS-Trust
    Page 2 · response
    Published 26 February 2018

    Open published response

  9. Manchester West

    AI-generated summary

    Helen Theresa Cannon · 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

    Helen Theresa Cannon fell at home on 2 April 2017 and was assisted from the floor by Eldercare emergency responders without medical or paramedic assistance being sought. She had suffered internal haemorrhage from a pelvic fracture sustained in the fall and died two days later; concerns were also identified about inaccuracies in the moving and handling risk assessment and flaws in Eldercare’s subsequent investigation.

    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 ensure understanding of the meaning of countersigning risk assessment checklists

    Wider context from the report

    “2. Following Mrs Cannon’s death Eldercare carried out an investigation. The investigation was flawed in that it did not address clear inaccuracies in the Moving and Handling Risk assessment checklist completed by one of the Emergency Responders, nor did it discover that the other Emergency Responder attending did not understand that he was agreeing with the accuracy of the information recorded on the checklist when he countersigned it. It was his belief that he signed the checklist simply to agree that he had been present. ”

    Source location

    Helen Theresa Cannon · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Black Country

    AI-generated summary

    Mrs Beryl Farmer · 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 Farmer was admitted to hospital with severe hypocalcaemia and postural hypotension, fell from her bed and sustained facial and head injuries, and was discharged without a documented falls risk assessment. She was readmitted after developing headaches, was diagnosed with a subdural haemorrhage, later developed seizures, and died; concerns included inadequate falls-risk assessment, moving her to an unmonitored bay, limited neurological observations, and no CT head scan after the fall.

    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 completed falls risk assessments

    Wider context from the report

    “1. Evidence emerged during the inquest that Mrs Farmer had a risk of a falling (moderate to high risk). There was no evidence that a falls risk assessment had been completed. ”

    Source location

    Mrs Beryl Farmer · 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