Recurring concern
Inadequate control of falls risks
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Request correctionFirst reported 31 Oct 2013•Latest report 21 May 2026
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
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
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.
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Concerns raised1
Failure of staff to sufficiently understand falls policies and procedures for consistent and appropriate implementation
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Disseminate falls policies and require staff policy acknowledgements on joining and annually.
Stated by Coxbench Hall Ltd
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Concerns raised2
Inadequate quality and extent of handover instructions to agency staff
Removal and unplugging of falls mat and sensor for high-falls-risk residents
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Provide agency staff with robust handovers and clear resident-care guidelines when their use is necessary.
Stated by BIOcareM -
Action
Create precise care plans for residents using crash mats or sensor mats, including placement, equipment condition and safe-use guidance.
Stated by BIOcareM -
Action
Highlight crash-mat and sensor-mat use in bold on daily handover sheets to alert new and agency staff.
Stated by BIOcareM
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Action
Add daily mattress-check documentation requiring staff to confirm equipment placement, settings and working condition.
Stated by BIOcareM -
Action
Include the risks of unplugging sensor mats or moving crash mats in in-house moving and handling training for staff.
Stated by BIOcareM
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Concerns raised6
Failure to complete, review and enforce falls risk assessments
Failure to address falls risk at handover
Failure to address and follow up escalated falls-prevention concerns
Failure to recognise and implement required fall-prevention interventions
Failure to ensure bed-rail use follows bed-rail risk assessments
Failure to document falls risk assessments and fall-prevention interventions
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Review the Falls Risk Assessment and Care Plan to align it explicitly with NICE falls-prevention guidance.
Stated by East Kent Hospitals University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The current falls policy and risk assessment tool reflect NICE guidance and address known factors that reduce inpatient falls risk.
Stated by East Kent Hospitals University NHS Foundation Trust
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Concerns raised3
Inadequate monitoring and enforcement of falls prevention policies and procedures
Failure to complete and review adequate falls risk assessments
Inadequate policies and procedures for falls risk assessment
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.2
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Action
Continue timely and adequate falls risk assessments for patients.
Stated by East Kent Hospitals University NHS Foundation Trust -
Action
Review the Falls Risk Assessment and Care Plan to explicitly incorporate relevant NICE falls-prevention guidance.
Stated by East Kent Hospitals University NHS Foundation Trust
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Concerns raised3
Failure to implement required falls precautions
Failure to maintain adequate, complete, current and enforced falls risk assessments
Inappropriate use of bed rails
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to supervise patients in the toilet unless a fall has occurred
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to provide nursing staff with instructions on the operational integrity of essential falls-risk equipment
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of effective interim management of residents at high risk of falls pending 1:1 care
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Outline interim steps in the Falls Prevention Policy to manage resident falls risk while funding decisions are pending.
Stated by St Medana Holdings Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Falls may still occur despite 1:1 supervision or supervision in communal areas, so increased supervision does not eliminate the risk.
Stated by St Medana Holdings Limited
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Concerns raised1
Failure of bed-fall risk assessments to provide consistent and coherent answers
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Implement personalised nursing care plan documentation, including bed-rail and falls assessments, across all inpatient areas.
Stated by Great Western Hospitals NHS Foundation Trust
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Concerns raised1
Failure to provide close supervision in the hospital room following review of the falls risk assessment
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 concernsEach statement is shown once, even when linked to more than one concern.
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.2
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Action
Develop and pilot an Enhanced Care SOP with a risk assessment tool and criteria for heightened observation of vulnerable adult inpatients.
Stated by South Tyneside and Sunderland NHS Foundation Trust -
Action
Ratify and roll out the Enhanced Care SOP across the Trust.
Stated by South Tyneside and Sunderland NHS Foundation Trust
Data last updated 7 September 2026