Recurring concern

Inadequate control of falls risks

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First reported 31 Oct 2013•Latest report 21 May 2026

Definition

What this concern includes

Includes assessment, care planning, equipment, supervision, handover, referral, reporting, post-fall response and assurance explicitly dedicated to falls risk.

Not included

Generic mobility, staffing or environmental failures not explicitly tied to falls
The occurrence of a fall without an identified control deficiency
Falls from windows where the asserted control is the design or restriction of the window

Reports: 165
Individual concerns: 285
Date range: 2013–2026
Stated actions: 349

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.

Department of Health and Social Care14

Care Quality Commission9

Barts Health NHS Trust6

Office of the Chief Coroner5

Aneurin Bevan University LHB4

Manchester University NHS Foundation Trust4

Royal London Hospital4

University Hospitals Sussex NHS Foundation Trust4

East Kent Hospitals University NHS Foundation Trust3

Hc-One Limited3

Swansea Bay University Local Health Board3

University Hospitals Birmingham NHS Foundation Trust3

Barchester Healthcare Limited2

Borough Care Ltd2

Cardiff & Vale University LHB2

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.

21 May2026
County Durham and Darlington
Concerns raised1
1. Failure to supervise residents at high risk of falls in the lounge area
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Patricia Mary BARNETT · 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

Patricia Mary BARNETT died on 13 March 2026 from a head injury sustained in an unwitnessed fall at a care home on 26 February 2026. The principal concern was that she, a resident with reduced mobility, cognitive impairment and a high risk of falls, had been left unsupervised in the lounge area, creating a risk of future deaths.

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 supervise residents at high risk of falls in the lounge area
Wider context from the report
“I am concerned that Mrs Barnett was left unsupervised in the lounge area. I am concerned that there is risk that future deaths could occur if residents who are suffering from reduced mobility and cognitive impairment and who are at high risk of falls are left unsupervised in the lounge area of the care home. ”
Source location
Patricia Mary BARNETT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
1 May2026
Birmingham and Solihull
Concerns raised2
1. Failure to investigate falls and implement adequate learning actions
2. Failure to provide appropriate observation in accordance with falls risk assessments and care plans
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Review every reported patient fall through local and central falls-team processes, identify learning, and implement appropriate corrective actions.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
2. Action
  Disseminate fall-related learning and required actions to ward staff through Listen Learn Share forms and electronic RADAR alerts.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
3. Action
  Provide falls training covering the learning identified from the incidents, with staff attendance completed or being arranged.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated in progress
1. Action
  Reinforce ward handovers remaining inside patient bays through daily safety-huddle reminders and stay-in-the-bay armbands, with compliance monitoring.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
2. Action
  Escalate staffing and patient-dependency pressures daily while reviewing ward establishment levels to address increased dependency.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated in progress
Respondent positions 3
1. Position
  Existing local and corporate falls reviews, learning, and actions were considered sufficient; no further action was proposed.
  Stated by University Hospitals Birmingham NHS Foundation TrustExisting arrangements considered sufficient
1. Position
  The falls team considered no further investigation necessary from its perspective, leaving further investigation to the ward team’s local process.
  Stated by University Hospitals Birmingham NHS Foundation TrustRedirects responsibility
2. Position
  No further action was considered necessary for the November fall because the patient was receiving end-of-life care under the medical team’s plan.
  Stated by University Hospitals Birmingham NHS Foundation TrustNo action considered necessary
AI-generated summary

John McKinlay · 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 McKinlay died at Beech Hill Grange nursing home on 19 November 2025 after receiving end-of-life care. His death involved natural causes alongside a subdural haematoma and fractured neck of femur associated with a series of falls, including inpatient falls at Good Hope Hospital, Birmingham Heartlands Hospital and Queen Elizabeth Hospital. The principal concern was that some falls may have occurred without the observation required by his falls risk assessment and care plan, and that evidence was not provided of investigations into falls at Birmingham Heartlands Hospital and Queen Elizabeth Hospital.

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 investigate falls and implement adequate learning actions
Wider context from the report
“The evidence from witnesses was that Mr McKinlay had a total of 4 falls whilst an inpatient at the University Hospitals of Birmingham: on the 11th September 2025 at Good Hope Hospital, 28th September 2025 at Birmingham Heartlands Hospital and on the 10th and 12th November 2025 at Queen Elizabeth Hospital. Some, potentially all, of the falls occurred when Mr McKinlay was not receiving the appropriate level of observation in accordance with his falls risk assessment and care plan. He sustained a femur fracture requiring operative fixation from the fall on the 11th September and an acute bleed of a pre-existing subdural haemorrhage on the 28th September. He did not have any investigations into the November falls as he was already receiving end of life care and there was no clinical evidence of injury. There has been a mortality review of the events at Good Hope Hospital, including the fall on the 11th September. However, evidence has not been provided of investigations into the falls at Birmingham Heartlands Hospital and Queen Elizabeth Hospital. It therefore cannot be determined that appropriate lessons have been learnt and adequate action taken creating a risk the situation has not improved. ”
Source location
John McKinlay · Prevention of Future Deaths report
Page 4 · 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
Failure to provide appropriate observation in accordance with falls risk assessments and care plans
Wider context from the report
“The evidence from witnesses was that Mr McKinlay had a total of 4 falls whilst an inpatient at the University Hospitals of Birmingham: on the 11th September 2025 at Good Hope Hospital, 28th September 2025 at Birmingham Heartlands Hospital and on the 10th and 12th November 2025 at Queen Elizabeth Hospital. Some, potentially all, of the falls occurred when Mr McKinlay was not receiving the appropriate level of observation in accordance with his falls risk assessment and care plan. He sustained a femur fracture requiring operative fixation from the fall on the 11th September and an acute bleed of a pre-existing subdural haemorrhage on the 28th September. He did not have any investigations into the November falls as he was already receiving end of life care and there was no clinical evidence of injury. There has been a mortality review of the events at Good Hope Hospital, including the fall on the 11th September. However, evidence has not been provided of investigations into the falls at Birmingham Heartlands Hospital and Queen Elizabeth Hospital. It therefore cannot be determined that appropriate lessons have been learnt and adequate action taken creating a risk the situation has not improved. ”
Source location
John McKinlay · Prevention of Future Deaths report
Page 4 · 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
Review every reported patient fall through local and central falls-team processes, identify learning, and implement appropriate corrective actions.

Verbatim wording from the response
“All patient falls within our organisation are reviewed locally and also centrally by our governance and falls teams. We have a dedicated falls team and part of their role is to review every reported incident where a patient has suffered a fall. The service runs Monday to Friday. Each of Mr McKinley’s falls were incident reported and reviewed by a member of the falls team in a timely manner prior to the incident being closed.”

Source location
Response from University Hospitals of Birmingham NHS Foundation Trust
Page 2 · response
Published 30 June 2026
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 fall-related learning and required actions to ward staff through Listen Learn Share forms and electronic RADAR alerts.

Verbatim wording from the response
“A Listen Learn Share form was also completed with the learning identified and actions required and this was circulated to all staff to read.”

Source location
Response from University Hospitals of Birmingham NHS Foundation Trust
Page 3 · response
Published 30 June 2026
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
Provide falls training covering the learning identified from the incidents, with staff attendance completed or being arranged.

Verbatim wording from the response
“On 17 November 2025 the ward manager completed their local investigation into the incident and completed a Listen Learn Share form highlighting the non-adherence to the falls procedure and reminding staff of the importance of ensuring that relevant assessments were completed and a recommendation that they all re-familiarise themselves with the Trust falls procedure. The specific learning identified included; that staff must familiarise themselves with the post fall retrieval procedure to ensure that they are retrieving patients from the floor using the correct methods, to ensure that documentation is thorough in order to record specifics about a patient fall including what footwear the patient was wearing, what exactly was discussed with the patient’s next of kin, and also ensuring post fall observations are completed as per the Trust standards.”

Source location
Response from University Hospitals of Birmingham NHS Foundation Trust
Page 5 · response
Published 30 June 2026
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
Reinforce ward handovers remaining inside patient bays through daily safety-huddle reminders and stay-in-the-bay armbands, with compliance monitoring.

Verbatim wording from the response
“As set out within the Senior Sister’s statement shared with the Coroner’s office on 16 December, she spoke to staff to ascertain how the fall occurred. In response, staff reflected that they had undertaken a handover outside of the bay instead of inside the bay which ultimately led to Mr McKinlay being able to get up unaided. The whole team were reminded of the importance of staying in bays during subsequent daily safety huddles. Stay in the bay arm bands were also introduced in order to reinforce this further. The Senior Sister continues to monitor compliance with this and the falls team have confirmed they have received no further incidents from this ward in relation to falls occurring when staff are leaving their designated area to handover.”

Source location
Response from University Hospitals of Birmingham NHS Foundation Trust
Page 3 · response
Published 30 June 2026
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
Escalate staffing and patient-dependency pressures daily while reviewing ward establishment levels to address increased dependency.

Verbatim wording from the response
“The situation was escalated to the senior nursing team and contact was made with an external Trust to request a registered mental health nurse to support the ward. Cover was provided on this date. We are aware of an increase in dependency of patients on this ward and a review is being undertaken by the Matron of the establishment level with a view to changes in this to meet the changes in patient cohort.”

Source location
Response from University Hospitals of Birmingham NHS Foundation Trust
Page 4 · response
Published 30 June 2026
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
Existing local and corporate falls reviews, learning, and actions were considered sufficient; no further action was proposed.

Verbatim wording from the response
“A summary of the incident and findings from the scoping were also presented at a weekly Patient Safety Incident Review Group meeting on 8 January 2026. This meeting is chaired by a Deputy Chief Medical Officer and attended by specialty medical directors, senior nursing teams and governance leads. After considering the incident, the group concluded that there was no requirement for a formal investigation as the incident had already been thoroughly reviewed locally and the team had already reflected on the incident and put appropriate actions in place to prevent a similar incident occurring.”

Source location
Response from University Hospitals of Birmingham NHS Foundation Trust
Page 3 · response
Published 30 June 2026
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 falls team considered no further investigation necessary from its perspective, leaving further investigation to the ward team’s local process.

Verbatim wording from the response
“The falls team reviewed the incident on Monday 29 September 2025 and the incident was deemed to be low harm in light of the NORSe neurosurgery review above, therefore, no further investigation was deemed to be required by the falls team and this remained for local investigation by the ward team.”

Source location
Response from University Hospitals of Birmingham NHS Foundation Trust
Page 4 · response
Published 30 June 2026
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
No further action was considered necessary for the November fall because the patient was receiving end-of-life care under the medical team’s plan.

Verbatim wording from the response
“On the morning of 10 November 2025 the falls team contacted the ward team confirming that they had reviewed the incident and downgraded the severity of the fall from moderate to low harm as there were no significant injuries noted following medical reviews. Again, the falls team reviewed the RADAR form, the clinical noting, observations recorded and assessments completed as well as reading the notes to understand the course of events and management plan going forward. At this stage it was recorded that Mr McKinlay continued on the end-of-life pathway and no further action was deemed necessary as per the medical team plan. It is noted that Mr McKinlay’s daughter was made aware of the fall at 13.35 hours.”

Source location
Response from University Hospitals of Birmingham NHS Foundation Trust
Page 4 · response
Published 30 June 2026
Open published response
30 Mar2026
Berkshire
Concerns raised3
1. Failure to ensure accurate falls risk assessment data and outcomes
2. Lack of assessment and auditing of falls risk assessment accuracy
3. Failure of the post-falls proforma to prompt consideration of anticoagulation reversal and urgency
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
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 the post-falls proforma to prompt consideration of anticoagulation reversal and urgency
Wider context from the report
“2. Anti coagulation risk awareness The doctor who reviewed the CT results and neurosurgery advice after Mr Tarrant fell did not appreciate the urgency of the situation. I found in this inquest that due to timing issues this was not likely to have affected the outcome for Mr Tarrant. I heard from the consultant witness that the risks of anticoagulation are poorly understood. The post falls proforma was reviewed in court and, whilst it asked whether the patient was on anticoagulation medication, it did not provide a prompt about this during the post fall medical planning section. This led to a concern that the importance of considering and administering an anticoagulation reversal medication and the urgency of such a need may be underappreciated. ”
Source location
John Albert TARRANT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 Feb2026
East London
Concerns raised3
1. Failure to undertake adequate falls risk assessments
2. Failure to record falls
3. Failure to reassess falls risk after a fall
This report raised 6 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 7
1. Action
  Deliver targeted falls-prevention education through ward teaching, safety huddles, induction and refresher training.
  Stated by Barts Health NHS TrustStated completed
2. Action
  Require ward managers and nurses in charge to review new admissions each shift for completed falls assessments and care plans.
  Stated by Barts Health NHS TrustStated completed
3. Action
  Introduce routine ward-level audits of falls assessments and care plans, with governance escalation, tracked actions and re-audit.
  Stated by Barts Health NHS TrustStated completed
1. Action
  Implement a multidisciplinary falls quality-improvement programme covering footwear, medication review and post-fall multidisciplinary review.
  Stated by Barts Health NHS TrustStated completed
2. Action
  Introduce a mandatory post-fall care bundle and checklist requiring structured assessment, neurological observations, escalation triggers and clinical documentation.
  Stated by Barts Health NHS TrustStated completed
3. Action
  Reinforce contemporaneous documentation and communication of inpatient falls and significant safety events during nursing and medical handovers.
  Stated by Barts Health NHS TrustStated completed
4. Action
  Introduce an out-of-hours falls review protocol requiring the Duty Matron or Site Manager to review inpatient falls within two hours.
  Stated by Barts Health NHS TrustStated completed
Respondent positions 1
1. Position
  NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Urmila Patel · 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

Urmila Patel, aged 78, was admitted to hospital with suspected sepsis and later fell in a ward toilet on 29 June 2025. She subsequently deteriorated and died in hospital on 7 July 2025 after a CT scan identified a significant subdural haematoma. The concerns included inadequate falls-risk assessment, mobility care planning, supervision, assessment for intracranial bleeding, timely CT referral, and review of her warfarin 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
Failure to undertake adequate falls risk assessments
Wider context from the report
“1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel. 2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility. 3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls. 4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025. 5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025. 6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025. 7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall. 8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025. ”
Source location
Urmila Patel · 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
Failure to record falls
Wider context from the report
“1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel. 2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility. 3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls. 4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025. 5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025. 6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025. 7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall. 8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025. ”
Source location
Urmila Patel · 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
Failure to reassess falls risk after a fall
Wider context from the report
“1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel. 2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility. 3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls. 4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025. 5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025. 6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025. 7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall. 8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025. ”
Source location
Urmila Patel · 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
Deliver targeted falls-prevention education through ward teaching, safety huddles, induction and refresher training.

Verbatim wording from the response
“Targeted education has been delivered to nursing staff, focusing on the timely completion of falls risk assessments on admission, recognition of dynamic risk, and the importance of translating assessed risk into clear and practical care plans. This has been reinforced through ward-based teaching, safety huddles, and incorporation into local induction and refresher training.”

Source location
Response from Barts Health NHS Trust
Page 1 · response
Published 3 March 2026
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
Require ward managers and nurses in charge to review new admissions each shift for completed falls assessments and care plans.

Verbatim wording from the response
“Accountability has been strengthened through clearer expectations of ward leadership. Ward managers and nurses in charge are now required to review new admissions each shift to confirm that falls risk assessments and associated care plans have been completed, with prompt action taken where gaps are identified.”

Source location
Response from Barts Health NHS Trust
Page 1 · response
Published 3 March 2026
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
Introduce routine ward-level audits of falls assessments and care plans, with governance escalation, tracked actions and re-audit.

Verbatim wording from the response
“A programme of routine audit has been introduced to review both completion and quality of falls risk assessments and care plans. Findings are reviewed at ward level and escalated through Divisional Governance where required, with actions agreed, tracked, and re-audited.”

Source location
Response from Barts Health NHS Trust
Page 2 · response
Published 3 March 2026
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
Implement a multidisciplinary falls quality-improvement programme covering footwear, medication review and post-fall multidisciplinary review.

Verbatim wording from the response
“Falls prevention has also been strengthened through a multidisciplinary quality improvement programme, recognising the contribution of nursing, medical, therapy, and pharmacy teams. This includes initiatives focused on appropriate footwear, structured medication review (including medicines associated with increased falls risk), and consistent post-fall multidisciplinary review. To support assurance, a ward-level falls audit programme commenced on 2 February 2026, with the most recent audit completed on 14 April 2026. Early findings demonstrate high compliance with falls risk assessment (97.2%), improved initiation of falls care plans (83.3%), improved completion of lying and standing blood pressure (78%), and timely medical review following falls. These findings are reviewed through ward and divisional governance processes to support sustained improvement.”

Source location
Response from Barts Health NHS Trust
Page 2 · response
Published 3 March 2026
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
Introduce a mandatory post-fall care bundle and checklist requiring structured assessment, neurological observations, escalation triggers and clinical documentation.

Verbatim wording from the response
“A mandatory post-fall care bundle and checklist has been introduced for all inpatient falls. This ensures that each fall is managed as a clinical event requiring structured assessment and response, aligned to the Patient Safety Incident Response Framework.”

Source location
Response from Barts Health NHS Trust
Page 2 · response
Published 3 March 2026
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
Reinforce contemporaneous documentation and communication of inpatient falls and significant safety events during nursing and medical handovers.

Verbatim wording from the response
“Actions taken The Trust has reinforced expectations that all inpatient falls and significant safety events are documented contemporaneously and clearly communicated during both nursing and medical handover.”

Source location
Response from Barts Health NHS Trust
Page 3 · response
Published 3 March 2026
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
Introduce an out-of-hours falls review protocol requiring the Duty Matron or Site Manager to review inpatient falls within two hours.

Verbatim wording from the response
“Senior oversight has been enhanced through the introduction of an out-of-hours falls review protocol, requiring the Duty Matron or Site Manager to review all inpatient falls within two hours, providing assurance that appropriate actions and escalation have occurred.”

Source location
Response from Barts Health NHS Trust
Page 2 · response
Published 3 March 2026
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
NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.

Verbatim wording from the response
“Given the concerns you have raised I feel it is important that you receive a response directly from NHS England as it has oversight for the issues you raise. Therefore, my officials have contacted NHS England who have agreed to respond to you directly about the Prevention of Future Death report concerning Mrs Patel.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 3 March 2026
Open published response
25 Feb2026
East Riding and Hull
Concerns raised3
1. Incomplete falls risk documentation
2. Inaccurate falls risk assessments
3. Failure to update falls risk assessments as required
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Complete multidisciplinary post-fall debrief and SWARM review to identify systemic falls-prevention learning.
  Stated by Humber Health PartnershipStated completed
2. Action
  Introduce Ward 32 spot checks and leadership oversight of documentation and reassessment completion.
  Stated by Humber Health PartnershipStated in progress
3. Action
  Provide Falls Prevention Team educator support to Ward 32 staff on completing falls assessments and associated documentation.
  Stated by Humber Health PartnershipStated planned
1. Action
  Conduct a specialist falls audit or accreditation review of Ward 32 to identify gaps, recommend improvements, and assess measurable progress.
  Stated by Humber Health PartnershipStated in progress
2. Action
  Monitor training, falls assessments, transfer reassessments, documentation, delirium assessment, post-fall reviews, and audit findings through local and group governance.
  Stated by Humber Health PartnershipStated planned
3. Action
  Implement Ward 32 actions covering falls training, documented call-bell education, timely post-fall medical review, 4AT assessment, lying and standing blood pressure, transfer assessments, and AFLOAT checks.
  Stated by Humber Health PartnershipStatus unclear
4. Action
  Reinforce reassessment of relevant clinical assessments when patients transfer between clinical areas across inpatient wards.
  Stated by Humber Health PartnershipStated completed
Respondent positions 1
1. Position
  Falls risk had been recognised and multiple prevention measures were in place before the fall, despite shortcomings in transfer reassessment and documentation.
  Stated by Humber Health PartnershipDisputes the concern
AI-generated summary

Raymond John MORAN · 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

Raymond John Moran, who had metastatic prostate cancer and other significant comorbidities, died on 24 December 2025 after an unwitnessed fall in hospital caused a right femur fracture. The report identifies concerns that his falls risk assessment was inaccurate, was not updated as required, and was incompletely documented.

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
Incomplete falls risk documentation
Wider context from the report
“Evidence was heard at inquest that not only was the falls risk assessment inaccurate, but also, it was not updated as it should have been. In addition, the documentation was incomplete. ”
Source location
Raymond John MORAN · 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
Inaccurate falls risk assessments
Wider context from the report
“Evidence was heard at inquest that not only was the falls risk assessment inaccurate, but also, it was not updated as it should have been. In addition, the documentation was incomplete. ”
Source location
Raymond John MORAN · 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
Failure to update falls risk assessments as required
Wider context from the report
“Evidence was heard at inquest that not only was the falls risk assessment inaccurate, but also, it was not updated as it should have been. In addition, the documentation was incomplete. ”
Source location
Raymond John MORAN · 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
Complete multidisciplinary post-fall debrief and SWARM review to identify systemic falls-prevention learning.

Verbatim wording from the response
“Following the incident, the Trust undertook both an immediate post-fall debrief and a multidisciplinary post-fall SWARM review. Those reviews identified local learning, including the need to strengthen documentation and reassessment processes, particularly in relation to ensuring multifactorial falls assessments are completed and updated on transfer, ensuring recent falls history and other relevant risk factors are clearly reflected in the assessment, ensuring formal assessment of suspected confusion or delirium is undertaken where indicated, ensuring lying and standing blood pressure is reconsidered when a patient becomes more mobile enough for this to be completed, reinforcing expectations regarding timely medical review after a fall, and improving the consistency of contemporaneous recording of falls prevention activity and post-fall management.”

Source location
Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Page 2 · response
Published 2 March 2026
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
Introduce Ward 32 spot checks and leadership oversight of documentation and reassessment completion.

Verbatim wording from the response
“4. Additional ward-level assurance measures Further local assurance measures are being put in place within Ward 32 to improve completion of documentation and reassessments. These include increased spot checks by ward leadership, review of whether assessments have been completed at the start of the day and strengthened local oversight involving ward sisters and junior sisters. The purpose of this is to embed compliance and ensure incomplete documentation is identified promptly and addressed.”

Source location
Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Page 2 · response
Published 2 March 2026
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
Provide Falls Prevention Team educator support to Ward 32 staff on completing falls assessments and associated documentation.

Verbatim wording from the response
“5. Targeted support from the Falls Prevention Team The Falls Prevention Team has agreed to provide additional practical support to Ward 32, including educator input to work directly with staff on the ward in relation to the correct completion of assessments and associated documentation. This support is intended to help embed practice and improve consistency.”

Source location
Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Page 2 · response
Published 2 March 2026
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
Conduct a specialist falls audit or accreditation review of Ward 32 to identify gaps, recommend improvements, and assess measurable progress.

Verbatim wording from the response
“6. Specialist audit / accreditation review Ward 32 is being prioritised for a specialist falls audit / accreditation review to identify any remaining gaps, to provide targeted recommendations, and to support the ward in achieving the required standard. This will also provide further assurance regarding whether the actions taken have resulted in measurable improvement.”

Source location
Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Page 3 · response
Published 2 March 2026
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
Monitor training, falls assessments, transfer reassessments, documentation, delirium assessment, post-fall reviews, and audit findings through local and group governance.

Verbatim wording from the response
“9. Monitoring and assurance The Trust will monitor the effectiveness of these actions through local and group governance processes. This will include review of:”

Source location
Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Page 3 · response
Published 2 March 2026
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
Implement Ward 32 actions covering falls training, documented call-bell education, timely post-fall medical review, 4AT assessment, lying and standing blood pressure, transfer assessments, and AFLOAT checks.

Verbatim wording from the response
“1. Immediate local review and learning The incident was subject to an immediate post-fall debrief and subsequent multidisciplinary SWARM review. These identified a number of specific actions for Ward 32, including:”

Source location
Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Page 2 · response
Published 2 March 2026
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
Reinforce reassessment of relevant clinical assessments when patients transfer between clinical areas across inpatient wards.

Verbatim wording from the response
“2. Reinforcement of transfer reassessment requirements The Trust has reinforced with ward teams the requirement that, when a patient transfers between clinical areas, the relevant assessments must be reviewed and repeated in accordance with policy. This learning has been recognised not simply as a ward-specific issue but as a theme relevant to inpatient ward areas more broadly. The SWARM expressly identified this learning as applicable group wide.”

Source location
Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Page 2 · response
Published 2 March 2026
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
Falls risk had been recognised and multiple prevention measures were in place before the fall, despite shortcomings in transfer reassessment and documentation.

Verbatim wording from the response
“However, the Trust considers it important to clarify that the patient’s falls risk had been recognised during the admission and that a number of falls prevention measures were in place prior to the fall. The post-fall debrief and SWARM review record that the patient had access to the call bell and had previously used it, had non-slip socks in place, had an appropriate bed rail assessment with bed rails raised in accordance with that assessment, had a Zimmer frame at the bedside, and had a mobility plan of Zimmer frame with assistance of two. The reviews also record that he was identified as being at risk of falls, that a falls risk assessment had been completed on admission, and that the relevant falls prevention measures were in place, albeit with shortcomings in reassessment and documentation on transfer.”

Source location
Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Page 1 · response
Published 2 March 2026
Open published response
21 Jan2026
Worcestershire
Concerns raised1
1. Failure to complete falls risk assessments and care plans properly
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
20 Jan2026
South Yorkshire (Eastern)
Concerns raised1
1. Failure to complete inpatient post-fall reviews
This report raised 4 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 2
1. Action
  Deliver and reinforce multidisciplinary training on complete, contemporaneous clinical documentation, including post-fall records and neurological observations.
  Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progress
2. Action
  Embed requirements for attending doctors to document individualised post-fall neurological observation plans covering frequency, duration, review and escalation criteria.
  Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progress
AI-generated summary

Dennis Keith Price · 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

Dennis Keith Price, a 71-year-old man, died on 28 October 2024 after falling while making his way unescorted to the toilet during a hospital admission. He suffered a subdural haemorrhage after the fall, and concerns included incomplete post-fall review, unclear neurological-observation instructions, and delays or failures in responding to Nerve Centre alerts.

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 inpatient post-fall reviews
Wider context from the report
“1. Failure to properly complete the inpatient post fall review. ”
Source location
Dennis Keith Price · 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
Deliver and reinforce multidisciplinary training on complete, contemporaneous clinical documentation, including post-fall records and neurological observations.

Verbatim wording from the response
“The Trust recognises that training is fundamental in reinforcing the importance of complete, accurate and contemporaneous clinical documentation, and this remains a core component of all education delivered by the Patient Safety Team. In addition, targeted documentation training has been delivered by the Trust’s Solicitor/Legal Manager to Foundation Year 1 doctors on 11 September 2025, and to Preceptorship Nurses on 11 and 25 November 2025. This programme of education forms part of an ongoing initiative, with further lectures and seminars planned to ensure continued reinforcement of documentation standards across the organisation.”

Source location
2026-0037 - Response from Doncaster Royal Infirmary
Page 2 · response
Published 26 January 2026
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
Embed requirements for attending doctors to document individualised post-fall neurological observation plans covering frequency, duration, review and escalation criteria.

Verbatim wording from the response
“The Trust acknowledges the concern regarding the absence of consistently documented medical direction for the frequency and duration of neurological observations following Mr Price’s fall. While the Patient Falls Prevention and Management Policy (PAT/PS 11) provides guidance on post-fall management, learning has identified the need for clearer, explicit documentation by the attending doctor to ensure that neurological observation requirements, review arrangements and escalation plans are clearly defined and understood by the multidisciplinary team. As part of ongoing improvement, the Trust is reinforcing the expectation that a clear, individualised post-fall monitoring plan is documented following every fall, supported through strengthened documentation standards, targeted multidisciplinary training and continued emphasis on completion of the Inpatient Post-Fall Review.”

Source location
2026-0037 - Response from Doncaster Royal Infirmary
Page 2 · response
Published 26 January 2026
Open published response
17 Dec2025
Liverpool and the Wirral
Concerns raised1
1. Inaccurate assessment of individual falls likelihood and impact
This report raised 3 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 2
1. Action
  Review all residents’ care plans and documented falls-risk scores for accuracy.
  Stated by Activcare Ltd t/a Westwood Hall Nursing Home and Springcare LimitedStated completed
2. Action
  Provide refresher training to relevant staff on adjusting electronic falls-risk scores after care-plan reviews.
  Stated by Activcare Ltd t/a Westwood Hall Nursing Home and Springcare LimitedStated completed
Respondent positions 1
1. Position
  The falls risk was appropriately assessed and mitigated; the incorrect electronic risk score was a documentation error with no practical impact.
  Stated by Activcare Ltd t/a Westwood Hall Nursing Home and Springcare LimitedDisputes the concern
AI-generated summary

Dorothy Ann MACDONALD · 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

Dorothy Ann MACDONALD sustained a fractured neck of femur in an unwitnessed fall at her nursing home on 11 August 2025 and died in hospital on 22 August 2025 after being placed on palliative end-of-life care. The report raised concerns that her falls risk and the potential impact of a fall were repeatedly underestimated, and that staff training and referrals to the falls team were not consistently effective or used.

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
Inaccurate assessment of individual falls likelihood and impact
Wider context from the report
“The Deceased was assessed as needing to use a trolley or to have the support of staff to mobilise safely. Despite this, on multiple occasions (and even after the Deceased had fallen at the home, and had aroused concern by attempting to mobilise alone and without a trolley), staff assessed and documented her risk of falling as being at ‘low’ likelihood – a score of 2/5 on the likelihood scale. The Home Manager accepted that this repeated assessment was ‘always wrong’. It was later increased to 3/5, classed as a medium risk. In the court’s opinion this was also wrong. The likely impact of harm was assessed as 3/5 and described as ‘undesirable’. This underestimated the potential impact, as subsequent events proved. The Home Manager was unable to tell the court what rankings of 4 or 5 would represent. The Deceased died as a result of the fractured neck of femur she sustained in a fall at the Care Home. It ought to have been understood by nursing or other senior staff in a nursing home setting that such an injury would be of great seriousness in somebody presenting as the Deceased did, with a fatal outcome following hospital admission after such an injury not being uncommon. The court was told that such risk assessments might be made by any nurse, the Deputy Manager or the Home Manager, and that all had received relevant training. The court is not satisfied that the training was effective and/or was being adopted properly. In this case the assessment of the likelihood of risk was plainly wrong; and the court considers that the assessment of impact was also incorrect. As a result, the overall risk score (likelihood x impact) was understated. In this instance it probably did not make a difference to the control/mitigation measures put in place, but the court is concerned that under-estimation of an individual’s falls risk could place other (current/future) residents at risk of falls which might threaten their lives. The court would like to know what steps are being taken to ensure that all relevant staff have received, understood and consistently act upon suitable and sufficient training in the assessment of falls risk. ”
Source location
Dorothy Ann MACDONALD · 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
Review all residents’ care plans and documented falls-risk scores for accuracy.

Verbatim wording from the response
“To ensure this is the case we have undertaken a review of all residents’ care plans and documented risk scores to ensure that these numbers correctly reflect the identified falls risks. We have also provided refresher training to the relevant staff to ensure that these risk scores are appropriately adjusted on the system when risk assessments and care plans are reviewed and updated. This has been documented as a supervision.”

Source location
Response from Springcare West Wood Hall
Page 3 · response
Published 19 December 2025
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
Provide refresher training to relevant staff on adjusting electronic falls-risk scores after care-plan reviews.

Verbatim wording from the response
“To ensure this is the case we have undertaken a review of all residents’ care plans and documented risk scores to ensure that these numbers correctly reflect the identified falls risks. We have also provided refresher training to the relevant staff to ensure that these risk scores are appropriately adjusted on the system when risk assessments and care plans are reviewed and updated. This has been documented as a supervision.”

Source location
Response from Springcare West Wood Hall
Page 3 · response
Published 19 December 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 falls risk was appropriately assessed and mitigated; the incorrect electronic risk score was a documentation error with no practical impact.

Verbatim wording from the response
“I would therefore respectfully contend that Mrs Macdonald’s risk of falls was appropriately assessed, monitored, reviewed and identified as high prior to any falls occurring. I do accept that the numerical overall risk rating was not correctly updated on the electronic record system to reflect the identified increased risk, however, this omission had no practical impact on the care which was actually provided to Mrs Macdonald or the risk reduction measures which were put in place. These were comprehensive and entirely appropriate in all the circumstances and I note your findings in that regard.”

Source location
Response from Springcare West Wood Hall
Page 3 · response
Published 19 December 2025
Open published response
14 Nov2025
Manchester South
Concerns raised3
1. Failure to adhere to the falls policy for unwitnessed falls in residents on anticoagulation
2. Limited staff understanding of the falls policy for unwitnessed falls in residents on anticoagulation
3. Failure to complete and update falls risk assessments after falls
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 5
1. Action
  Implement falls protocols requiring every fall to be reported, digitally recorded and followed by reassessment when needs may have changed.
  Stated by The Lakes Care CentreStated completed
2. Action
  Retrain all Senior Carers on falls management, including seeking support and applying the falls protocol for unwitnessed falls involving anticoagulated residents.
  Stated by The Lakes Care CentreStated completed
3. Action
  Implement a Senior Falls Champion role responsible for coaching, training and assessing staff on falls and falls-risk management.
  Stated by The Lakes Care CentreStated completed
1. Action
  Adopt a comprehensive pre-admission protocol to create complete care plans and risk assessments from admission.
  Stated by The Lakes Care CentreStated completed
2. Action
  Allocate monthly care-plan and risk-assessment reviews to Senior Carers and Leaders, with interim updates communicated to staff.
  Stated by The Lakes Care CentreStated completed
AI-generated summary

Ronald PERRY · 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

Ronald Perry became increasingly frail after discharge to The Lakes Care Home and experienced several falls, including a fall on 25 April 2025 that resulted in a brain bleed and fractures. He deteriorated after surgery and died at Salford Royal Hospital on 30 May 2025. Concerns included poor care and risk documentation, incomplete falls risk assessments, and inconsistent adherence to the policy on seeking medical advice for unwitnessed falls involving residents on anticoagulants.

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 adhere to the falls policy for unwitnessed falls in residents on anticoagulation
Wider context from the report
“3. The falls policy regarding the need to seek medical advice where a resident on anticoagulation had a fall that had been unwitnessed did not seem to be widely understood by staff or adhered to on all occasions. ”
Source location
Ronald PERRY · 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
Limited staff understanding of the falls policy for unwitnessed falls in residents on anticoagulation
Wider context from the report
“3. The falls policy regarding the need to seek medical advice where a resident on anticoagulation had a fall that had been unwitnessed did not seem to be widely understood by staff or adhered to on all occasions. ”
Source location
Ronald PERRY · 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
Failure to complete and update falls risk assessments after falls
Wider context from the report
“2. The falls risk assessment documentation was incomplete and did not appear to have been updated after falls had occurred. ”
Source location
Ronald PERRY · 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 falls protocols requiring every fall to be reported, digitally recorded and followed by reassessment when needs may have changed.

Verbatim wording from the response
“The Lakes Care Centre now has clear guidelines and protocols to follow in all falls – whether serious or apparently innocuous. The guidance now direct people to report on every occasion (using Digital health – during operating hours, NHS 11 support or NHS 999 support).”

Source location
Response from The Lakes Care Centre
Page 3 · response
Published 18 November 2025
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
Retrain all Senior Carers on falls management, including seeking support and applying the falls protocol for unwitnessed falls involving anticoagulated residents.

Verbatim wording from the response
“The Lakes Care centre agrees that some people charged with supporting our residents, did not fully understand the policy and protocols that re in place when people experience falls at The Lakes Care Centre.”

Source location
Response from The Lakes Care Centre
Page 3 · response
Published 18 November 2025
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
Implement a Senior Falls Champion role responsible for coaching, training and assessing staff on falls and falls-risk management.

Verbatim wording from the response
“Finally, after all this soul searching and reviewing we have now implemented a Falls Champion at The Lakes. The Champion is a Senior Person and will undertake in collaboration with Nottingham University, a 5-week training and awareness training programme. This will equip them with the knowledge and skills to be able to effect positive responses to all falls and falls risk management. They will be responsible to coaching, training and assessing our teams for their approach to this subject.”

Source location
Response from The Lakes Care Centre
Page 4 · response
Published 18 November 2025
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
Adopt a comprehensive pre-admission protocol to create complete care plans and risk assessments from admission.

Verbatim wording from the response
“a) Pre/New Admission Protocol – we adopted a new and thorough approach which enables our team to ensure we have all information to create a full and complete Care Plan from Day 1 and ensure all accompanying Risk Assessments are in place to support the Care Plans.”

Source location
Response from The Lakes Care Centre
Page 2 · response
Published 18 November 2025
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
Allocate monthly care-plan and risk-assessment reviews to Senior Carers and Leaders, with interim updates communicated to staff.

Verbatim wording from the response
“b) Care Plan – Reviews These are now allocated to certain key individuals (All Seniors Carers and Leaders) to ensure all are checked at least monthly and any updates added. If changes occur in between reviews then the Care Plan and Riska assessments are updated accordingly and communicated with the teams.”

Source location
Response from The Lakes Care Centre
Page 2 · response
Published 18 November 2025
Open published response
23 Oct2025
Derby and Derbyshire
Concerns raised1
1. Relatively low perimeter wall creating a risk of fatal falls
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 2
1. Action
  Closed the car park’s top floor to the public using temporary fencing.
  Stated by Chesterfield Borough CouncilStated completed
2. Action
  Installed a permanent enhanced closure comprising full-height heavy-duty gates and fencing to prevent unauthorised access to the top floor.
  Stated by Chesterfield Borough CouncilStated completed
AI-generated summary

Mr Saranveer Singh Sihota · 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

Mr Saranveer Singh Sihota, known as Sunny, was a detained patient at a mental health unit who left without permission and died from injuries sustained after falling approximately 70 feet. The report identifies concerns about the relatively low perimeter wall at the location, the risk of fatal falls, and the possibility that others experiencing suicidal thoughts might use the location.

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
Relatively low perimeter wall creating a risk of fatal falls
Wider context from the report
“It is reported to me that the ████████ has a relatively low wall to it. Given the height of the top floor there appears to be a clear risk that, either deliberately or accidentally, people might fall to the ground with high chance of death. I am not aware of what barriers there may be to the perimeters of the lower floors. ”
Source location
Mr Saranveer Singh Sihota · 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
Closed the car park’s top floor to the public using temporary fencing.

Verbatim wording from the response
“Chesterfield Borough Council undertook a full investigation following the tragic death of Mr. Sihota, focusing on what measures could be taken to prevent future death or injury. ████████ first opened in 1981, with all floors including the top floor being used for car parking. Following Mr. Sihota’s death, the top floor of the car park was closed to the public immediately utilising temporary fencing.”

Source location
Response from Chesterfield Borough Council
Page 1 · response
Published 28 October 2025
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
Installed a permanent enhanced closure comprising full-height heavy-duty gates and fencing to prevent unauthorised access to the top floor.

Verbatim wording from the response
“A full closure scheme with enhanced suicide prevention measures was then developed to prevent any unauthorised access to the top floor permanently. This included the installation of full height, heavy duty gates and fencing. The permanent enhanced closure for the top floor of the car park was completed in March 2024. The following photos have been supplied to show the suicide prevention measures installed:”

Source location
Response from Chesterfield Borough Council
Page 1 · response
Published 28 October 2025
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to supervise residents at high risk of falls in the lounge area

Concerns raised2

Failure to investigate falls and implement adequate learning actions

Failure to provide appropriate observation in accordance with falls risk assessments and care plans

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.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised3

Failure to ensure accurate falls risk assessment data and outcomes

Lack of assessment and auditing of falls risk assessment accuracy

Failure of the post-falls proforma to prompt consideration of anticoagulation reversal and urgency

Concerns raised3

Failure to undertake adequate falls risk assessments

Failure to record falls

Failure to reassess falls risk after a fall

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.7

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

Concerns raised3

Incomplete falls risk documentation

Inaccurate falls risk assessments

Failure to update falls risk assessments as required

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.7

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 5

Respondent positions 3

Actions described in response 7

Respondent positions 1

Actions described in response 7

Respondent positions 1