Recurring concern

Unreliable control of stair-related fall risks in care placements

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First reported 22 Oct 2017•Latest report 12 Dec 2024

Definition

What this concern includes

Includes care-placement, admission, environmental-risk and care-planning controls specifically concerned with stair-related fall risks, including recording or assessing stairs and stair gates, evaluating locking mechanisms, providing or maintaining required rails or other aids, and reassessing safeguards after a fall or change in vulnerability.

Not included

Excludes general falls-risk assessment, post-fall response or mobility-care failures where no stair-related hazard or control is identified.
Excludes unrelated stair-lift, ramp, flooring, lighting and general building-safety deficiencies unless they directly concern the same stair-related fall-risk control in a care placement.
Excludes generic care-package, staffing, documentation or communication deficiencies unless they directly leave a known stair-related risk or required stair safeguard uncontrolled.
Excludes falls in hospitals, public roads or other settings unless the assertion concerns a comparable care-placement process for controlling stair-related risks.

Reports: 2
Individual concerns: 2
Date range: 2017–2024
Stated actions: 4

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Cardiff Council1

City of Doncaster Council1

Welsh Government1

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.

12 Dec2024
South Yorkshire (Eastern)
Concerns raised1
1. Care and support placement records omitting identified stair-related fall risks
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 1
1. Action
  Continue staff training and reinforce accurate recording of falls and other health-related events.
  Stated by City of Doncaster CouncilStated in progress
Respondent positions 1
1. Position
  The Council had no record that concerns about deteriorating ability on stairs were reported by family, carers or the individual.
  Stated by City of Doncaster CouncilDisputes the concern
AI-generated summary

Jean MULLEN · 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 Mullen, an 87-year-old woman, was found collapsed and unresponsive at the bottom of the stairs at home after her pendant alarm was triggered on 22 June 2024; the inquest concluded that her death was accidental, involving a fall from height, fracture of the neck and subdural haemorrhage. Concerns included the failure to provide a recommended grab rail, failure to escalate a fall in the shower or reassess her mobility and equipment needs, and incomplete recording of stair-related risks.

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
Care and support placement records omitting identified stair-related fall risks
Wider context from the report
“During the course of the inquest I heard evidence regarding communications between various departments of Adult Social Care and Home First and in particular STEPS. There had been an assessment by the therapist at Doncaster Royal Infirmary regarding Mrs Mullen returning to a safe home environment and what support and equipment would be required to allow that to take place. This included an assessment in the home with social workers present. A care package was provided by STEPS and it quickly became apparent that long term care and support would be required in the home and thus an application was completed on the 12th April. Mrs Mullen's family referred to them being informed that a grab rail would be required at the top of the stairs near the bathroom to help Mrs Mullen navigate to the bathroom thus reducing the risk of falls. This was not provided. A fall occurred when Mrs Mullen was in the shower but the carers failed to escalate this and made no referrals for any further assessment to take place in relation to Mrs Mullen's mobility and ability to continue living safely at her home address. Further this was a missed opportunity to assess whether any other aids or equipment were needed to support her. Had this taken place it is likely that the absence of the grab rail would have been identified. This was a further missed opportunity. Finally, the care and support placement referred to in the second exhibit to ████████'s report made no reference to the issue of stairs and the risk of falling that they presented. ”
Source location
Jean MULLEN · Prevention of Future Deaths report
Page 3 · 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 staff training and reinforce accurate recording of falls and other health-related events.

Verbatim wording from the response
“➢ All of our social care staff undergo specific training as a matter of course on the need for detailed accurate records to be maintained in care settings, including the recording of slips and falls and general health related events.”

Source location
Response from Doncaster Council
Page 1 · response
Published 20 February 2025
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
The Council had no record that concerns about deteriorating ability on stairs were reported by family, carers or the individual.

Verbatim wording from the response
“The Council does not have any record of Patricia Mullen informing social care that the stairs were becoming too much for her mother and neither was this identified as an issue by the carers. If any concern had been expressed by Patricia Mullen, and carers or Mrs Mullen herself (who had full capacity), this would have been recorded and investigated.”

Source location
Response from Doncaster Council
Page 3 · response
Published 20 February 2025
Open published response
22 Oct2017
South Wales Central
Concerns raised1
1. Failure of care and risk assessments to consider stair-gate and locking-mechanism risks
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 3
1. Action
  Implement and maintain an agreed referral pathway clarifying responsibilities for environmental-control assessments, including joint occupational-therapy assessment of stairgate requests.
  Stated by Cardiff CouncilStated completed
2. Action
  Develop and consult staff on stairgate assessment guidance and an assessment tool for evaluating stairgate risks.
  Stated by Cardiff CouncilStated completed
3. Action
  Enhance monthly health-and-safety checklists and prescribed safety logs with prompts covering stairs, stairgates and related risks.
  Stated by Cardiff CouncilStated completed
Respondent positions 1
1. Position
  Council policies, processes and partner arrangements adequately address recommended reviews of stair suitability and supported-living risk, supervision and control.
  Stated by Cardiff CouncilExisting arrangements considered sufficient
AI-generated summary

Lesley Hanson · 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

Lesley Hanson, who had severe learning disabilities and poor stability, gained access to stairs at her supported accommodation on 11 March 2017 and fell, sustaining injuries that led to her death. The concerns were that care and risk assessments did not address the gate being left open, the type of stair-gate or locking mechanism, and that responsibility for environmental safety controls was unclear. The inquest jury found the arrangements inadequate, including failure to follow the service plan and repeated occasions when the stair-gate had been left open.

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 of care and risk assessments to consider stair-gate and locking-mechanism risks
Wider context from the report
“(1) The evidence revealed that the care and risk assessments did not appear to consider the impact of the gate being left open by other residents, the type of stair-gate and the suitability of the locking mechanism. ”
Source location
Lesley Hanson · 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 and maintain an agreed referral pathway clarifying responsibilities for environmental-control assessments, including joint occupational-therapy assessment of stairgate requests.

Verbatim wording from the response
“1.3 Where assessments for environmental controls are required, the Senior Support Worker (or delegated member of staff) will complete a referral form and forward to ABMU Learning Disability Health Team or the Cardiff Communities Occupational Therapy Team (CCOT) depending on the nature/size of the work requested. A ‘Referral Pathway’ flowchart has been designed to ensure consistency of process. This flowchart has been subject to consultation with the ISL Manager Supported Living Coordinator, Learning Disability Social Services Team Managers, ABMU Health Team Manager and Cardiff Occupational Therapists.”

Source location
2017-0303-Response
Page 2 · response
Published 27 November 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
Develop and consult staff on stairgate assessment guidance and an assessment tool for evaluating stairgate risks.

Verbatim wording from the response
“1.7 As a result of the fatal incident ABMU Learning Disability Occupational Therapist has developed a Stairgate Factsheet and an Assessment Tool. These documents identify that as far as can be ascertained (after extensive searches) there is no specific guidance (from an appropriate Statutory Regulator) on use of stairgates for adults. They have therefore been developed having regard to good practice and advice provided by professional bodies in order to provide a thorough checklist for staff that are undertaking assessments. These documents have been consulted with Cardiff Communities Occupational Therapy colleagues, the Supported Living Co-ordinator and Cardiff Council’s Operational Manager for Health and Safety.”

Source location
2017-0303-Response
Page 2 · response
Published 27 November 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
Enhance monthly health-and-safety checklists and prescribed safety logs with prompts covering stairs, stairgates and related risks.

Verbatim wording from the response
“3.1 The Internal Supported Living Service (ISL) has a prescribed system of checks for which all senior support staff are trained by the Compliance Officer, Housing and Neighbourhood Team. These are recorded in the ‘Fire, Health and Safety and General Maintenance Log Book’. In addition to this, a comprehensive monthly ‘Health and Safety Checklist’ has been enhanced in collaboration with Cardiff Council’s Operational Manager for Health and Safety. This includes reference to stairs and stair gates with additional prompts to staff regarding specific issues to consider.”

Source location
2017-0303-Response
Page 4 · response
Published 27 November 2017
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
Council policies, processes and partner arrangements adequately address recommended reviews of stair suitability and supported-living risk, supervision and control.

Verbatim wording from the response
“Since the tragic death of Lesley Hanson on the 13 March 2016, there has been an extensive review undertaken by the Council which has resulted in improvements to policy and processes involving council staff, services and our partners in Abertawe Bro Morgannwg University Health Board (ABMU). The improvements made have been communicated to the Health and Safety Executive and address the following actions raised in your Regulation 28 Report:-”

Source location
2017-0303-Response
Page 1 · response
Published 27 November 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Care and support placement records omitting identified stair-related fall risks

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure of care and risk assessments to consider stair-gate and locking-mechanism risks

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 1

Respondent positions 1

Actions described in response 3

Respondent positions 1