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. 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

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