Recurring concern

Unreliable control of stair-related fall risks in care placements

First to latest report 22 Oct 2017 — 12 Dec 2024

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
4

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.

What is 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 and published responses 2 reports

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

  1. South Yorkshire (Eastern)

    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

  2. South Wales Central

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026