Recurring concern

Unreliable completion and verification of falls-risk assessments

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First reported 10 Dec 2015•Latest report 30 Mar 2026

Definition

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.

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
11

Distinct published reports

Individual concerns
13

A report can raise multiple concerns

Date range
2015–2026

First to latest report issue date

Stated actions
8

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.

Care Quality Commission2
Aneurin Bevan University LHB1
Beechwood Lodge1
Cardinal HC Limited1
Cole Valley Care Limited1
Department of Health and Social Care1
East Kent Hospitals University NHS Foundation Trust1
Eldercare (UK) Limited1
Frimley Health NHS Foundation Trust1
Merthyr Tydfil County Borough Council1
Ministry of Housing, Communities and Local Government1
Sandwell and West Birmingham Hospitals NHS Trust1
Tricuro Ltd1
Wigan Borough Council1
Your Health Limited1

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. Nottinghamshire

    AI-generated summary

    Elsie Marjorie Brown · 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

    Elsie Marjorie Brown fell from her bed at Langwith Lodge Residential Care Home on 23 March 2015, suffering fractures to her left humerus and right hip. She died in hospital on 5 April 2015 from bronchopneumonia and lobar pneumonia, which developed as a result of the fractures. Concerns included the absence of falls-risk and bed-rails assessments, an incomplete and unreviewed care plan, unclear responsibilities, inadequate recording and handovers, insufficient auditing, and potentially inadequate night staffing.

    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 falls risk assessments

    Wider context from the report

    “1. There was no falls risk assessment nor bed rails assessment in place for Mrs Brown, nor was her mental capacity assessed. ”

    Source location

    Elsie Marjorie Brown · 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

    Use a multifactorial falls risk assessment covering nighttime risks.

    Verbatim wording from the response

    “The Company did have corporate documentation in relation to falls risk assessment at the time of the incident. The ‘Multi-factorial falls risk assessment’ (attached) was introduced in 2014. This documentation allows Senior and Managerial staff to assess the likelihood of a resident suffering a fall and includes a section about the risks at night time.”

    Source location

    Elsie-Brown-Response
    Page 1 · response
    Published 4 December 2015

    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

    Use a falls management folder containing assessment tools, including a bed-rail risk assessment and algorithm.

    Verbatim wording from the response

    “A falls management folder was introduced at Langwith in April 2015, which contains a number of different assessment tools to assist staff in reviewing the safety of a resident who is at risk of falls. This includes a specific bed rail risk assessment and algorithm (attached).”

    Source location

    Elsie-Brown-Response
    Page 2 · response
    Published 4 December 2015

    Open published response
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Data last updated 7 September 2026