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.

26 Jul2017
York City
Concerns raised1
1. Unavailability of falls sensors for patients assessed at risk of falls
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

KENNETH JOHN SWIFT · 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

Kenneth John Swift was admitted to York Hospital with community acquired pneumonia and, while assessed as being at risk of falls, fell unaccompanied on 21 April 2017 and fractured his neck of femur. He died in hospital on 28 April 2017. The principal concern was that no falls sensor was immediately available despite his assessed risk and attempts to mobilise without supervision, raising concerns about the potential for similar fall-related harm to other patients.

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
Unavailability of falls sensors for patients assessed at risk of falls
Wider context from the report
“(1) Although assessed as being at risk of falls and despite being positioned in a bay that was close to the Nurses’ Station in the Ward for better observation, Mr Swift was also recommended to have a falls sensor as he was observed by occupational therapist and physiotherapist trying to mobilise without supervision despite advice not to do so. (2) It was said in evidence that: No falls sensor was immediately available- Mr Swift was put on a ‘waiting list’ of 34 existing patients needing such equipment. The cost of a chair sensor was said to be £60; of a bed sensor £90. The Hospital was said to be in a tendering process to acquire such equipment. In the relevant Ward (AMU/AMB) 95% of the usual 30 patients (when full) at any one time would have been assessed at risk of falls. Four sensors have been acquired since Mr Swift’s death for use at the present time in that Ward. (3) Such a mechanism may have made staff aware that Mr Swift, an elderly man known to be capable of confusion and already suffering from infection that could be aggravated by immobility if injured, was mobilising unsupervised. (4) That in this Ward at least there is the potential for future deaths resulting from, or the aggravation of, conditions by the consequences of falls in other patients. ”
Source location
KENNETH JOHN SWIFT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Jul2017
Birmingham and Solihull
Concerns raised2
1. Failure to offer analgesia to residents reporting pain after a fall
2. Failure to make the falls protocol clearly available to staff
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 1
1. Action
  Disseminate the falls protocol to staff and incorporate it into new-staff induction.
  Stated by Care First Class (UK) LimitedStated completed
Respondent positions 1
1. Position
  Care staff cannot administer non-prescribed pain relief because the home is not a nursing home and staff lack necessary clinical skills.
  Stated by Care Quality CommissionUnable to act
AI-generated summary

James Albert Harris · 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

James Albert Harris died in hospital on 3 April 2017 after a fall at his care home, sustaining a fractured neck of femur and subsequently deteriorating with pneumonia, Clostridium difficile infection and underlying health conditions. Concerns included inadequate falls-policy awareness and application, failure to seek medical attention after he reported pain, lack of analgesia, inadequate records of routine checks, and the care home being without a registered manager.

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 offer analgesia to residents reporting pain after a fall
Wider context from the report
“4. Mr. Harris was not offered any analgesia despite his reports of pain. ”
Source location
James Albert Harris · Prevention of Future Deaths report
Page 1 · 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 make the falls protocol clearly available to staff
Wider context from the report
“3. Having fallen Mr. Harris complained of pain in his groin. The home’s ‘Protocol for all Falls’ included that if the resident complains of pain in any part of the body following a fall they ought not to be moved and medical attention should be sought. Medical attention was not sought and Mr. Harris was returned to his room. The three carers who gave evidence at the inquest ████████ ████████ and ████████ all gave evidence that they had not seen the document entitled ‘Protocol for all Falls’ prior to Mr. Harris’ fall on the 26th January 2017, although ████████ and ████████ were not found to be credible witnesses, ████████ was credible. Evidence of police investigations identified that the Protocol ought to have been clearly available for staff around the home as a result of issues raised by the CQC prior to this incident. ”
Source location
James Albert Harris · 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
Disseminate the falls protocol to staff and incorporate it into new-staff induction.

Verbatim wording from the response
“3) Protocol for falls – this document has been given to all staff and a signed copy is kept on their personnel file. This has also been made part of the induction protocol for new staff.”

Source location
2017-0334-Response-by-Care-First-Class-UK
Page 1 · response
Published 2 December 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
Care staff cannot administer non-prescribed pain relief because the home is not a nursing home and staff lack necessary clinical skills.

Verbatim wording from the response
“The Registered Provider had a system to ensure that service users received their prescribed medication, including medicines prescribed on an as required basis. However, individual care staff had not followed the provider’s protocol when Mr Harris complained of pain. The policy of the Cherry Lodge was not to offer or keep homely remedies on the premises. This means, if a service user required pain relief not already prescribed by a GP, a care worker cannot administer the medicine. In such an event, the Registered Provider’s protocol is to call for assistance either through 111 or 999. Cherry Lodge is not a nursing home and as such care staff do not have the necessary clinical skills to make judgments about people’s health, or the risk associated with administering medication that had not been prescribed.”

Source location
2017-0334-Response-by-Care-Quality-Commission
Page 6 · response
Published 2 December 2017
Open published response
18 Jul2017
Manchester South
Concerns raised2
1. Inaccurate falls-risk documentation
2. Lack of understanding of reviews and required post-fall processes
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 4
1. Action
  Audit documentation on service users’ falls and mobility.
  Stated by Fairfield View Care CentreStated completed
2. Action
  Audit care plans and daily records daily and weekly for accurate risk assessments and fall documentation.
  Stated by Fairfield View Care CentreStated in progress
3. Action
  Provide care-planning training covering accurate risk assessments, service-user needs, documentation and involvement in care planning.
  Stated by Fairfield View Care CentreStated planned
1. Action
  Brief staff on documentation requirements and the falls procedure, including lessons from the identified failings.
  Stated by Fairfield View Care CentreStated completed
AI-generated summary

Ivy Mitchell · 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

Ivy Mitchell, a care home resident with a history of falls, fell on 29 December 2016 and later developed a subcapital fracture and pneumonia. She deteriorated and died on 26 January 2017; concerns included inaccurate falls-risk documentation, inadequate understanding of post-fall processes and observations, failure to escalate appropriately, and lack of understanding about referral to the community nutrition team.

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 falls-risk documentation
Wider context from the report
“1. The documentation relating to the falls risk was inaccurate. It did not refer to previous falls and did not reflect her mobility; ”
Source location
Ivy Mitchell · 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 understanding of reviews and required post-fall processes
Wider context from the report
“2. There was a lack of understanding amongst the care home staff of risk assessments; reviews and the required process following a fall. This included documenting observations after a fall. ”
Source location
Ivy Mitchell · 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
Audit documentation on service users’ falls and mobility.

Verbatim wording from the response
“I enclose my reply, in response to regulation 28 in the case of Mrs Ivy Mitchell. I have now audited all the documentation in relation to falls and mobility of all the service users. In relation to Mrs Mitchell, I accept that the documentation and risk assessments did not accurately reflect her falls or mobility, which has caused me great concern.”

Source location
2017-0453-Response-by-Fairfield-View-Care-Centre
Page 1 · response
Published 18 July 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
Audit care plans and daily records daily and weekly for accurate risk assessments and fall documentation.

Verbatim wording from the response
“Senior staff attended the meeting ████████ held in relation to documentation and the falls procedure. Details of which, I enclose. This information has been cascaded down to staff, and the importance of completing all the relevant documentation was discussed at length. I have emphasised the failings in relation to Mrs Mitchell, and that we must ensure it does not happen again to any of the service users. I am now auditing all care plans and daily records on a daily and weekly basis, to ensure accuracy regarding risk assessments, and that documentation in the event of a fall is completed accurately and in a timely manner.”

Source location
2017-0453-Response-by-Fairfield-View-Care-Centre
Page 1 · response
Published 18 July 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
Provide care-planning training covering accurate risk assessments, service-user needs, documentation and involvement in care planning.

Verbatim wording from the response
“Unit Managers, Deputies and Senior Care Staff are undertaking a course on care planning, this will commence in September of this year with Tameside College. This will include how to complete an accurate risk assessment as well as identifying the needs of the service user. This course will provide them with more knowledge about the importance of documentation and of the need to involve the service user, where there is capacity, or their relatives in all care planning activities.”

Source location
2017-0453-Response-by-Fairfield-View-Care-Centre
Page 1 · response
Published 18 July 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
Brief staff on documentation requirements and the falls procedure, including lessons from the identified failings.

Verbatim wording from the response
“Senior staff attended the meeting ████████ held in relation to documentation and the falls procedure. Details of which, I enclose. This information has been cascaded down to staff, and the importance of completing all the relevant documentation was discussed at length. I have emphasised the failings in relation to Mrs Mitchell, and that we must ensure it does not happen again to any of the service users. I am now auditing all care plans and daily records on a daily and weekly basis, to ensure accuracy regarding risk assessments, and that documentation in the event of a fall is completed accurately and in a timely manner.”

Source location
2017-0453-Response-by-Fairfield-View-Care-Centre
Page 1 · response
Published 18 July 2017
Open published response
20 Apr2017
Brighton and Hove
Concerns raised1
1. Reliance on reactive rather than proactive falls prevention
This report raised 7 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

Patricia Margherita WEBB · 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 Margherita WEBB was an 86-year-old woman who was admitted to hospital after which she experienced six falls, fracturing her hip in the sixth fall. The report raised concerns about fall prevention, observation and meaningful activity, footwear and mobility, staffing and ward layout, handover arrangements, resources, and delays in discharge.

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
Reliance on reactive rather than proactive falls prevention
Wider context from the report
“(3) In the Royal Sussex County Hospital, I understand there is to be or already taking place a trial of ‘buzzer alerts’ for Nurses – I am sure this is an extremely good idea but feel that it may be more profitable to be proactive rather than reactive. ”
Source location
Patricia Margherita WEBB · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Mar2017
Norfolk
Concerns raised2
1. Absence of falls planning and prevention
2. Failure to use available movement-alert and fall-prevention equipment
This report raised 9 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 6
1. Action
  Continue upgrading and periodically reviewing the Trust’s falls prevention plan.
  Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated in progress
2. Action
  Run the falls campaign and continue staff work to improve awareness of the falls assessment process.
  Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated in progress
3. Action
  Continue ward training on assessing patients at risk of falls.
  Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated in progress
1. Action
  Identify falls champions on Windsor ward.
  Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completed
2. Action
  Pilot the bed-rails assessment document, require daily completion, and assess compliance and effectiveness before any Trust-wide rollout.
  Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated in progress
3. Action
  Establish an intranet site containing resources for safe falls assessment.
  Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completed
AI-generated summary

James Charles MALLETT · 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

James Charles Mallett, aged 93, was admitted to hospital after a fall at home and later sustained a fatal head injury in a further inpatient fall. Concerns included delayed medical attendance, unclear and untimely neurological observations, inadequate contemporaneous records, insufficient falls prevention, and nursing staff training and experience that were considered inadequate.

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
Absence of falls planning and prevention
Wider context from the report
“4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett. There was no falls planning or prevention, there was no care plan in place on this ward. There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement. The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor. ”
Source location
James Charles MALLETT · Prevention of Future Deaths report
Page 1 · 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 use available movement-alert and fall-prevention equipment
Wider context from the report
“4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett. There was no falls planning or prevention, there was no care plan in place on this ward. There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement. The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor. ”
Source location
James Charles MALLETT · 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
Continue upgrading and periodically reviewing the Trust’s falls prevention plan.

Verbatim wording from the response
“I write in my capacity as Interim Director of Nursing to respond formally to the Regulation 28 Report. I would like to assure you that the matter of in-patient falls within the organisation is taken very seriously and considered regularly at Board level, and by the Non-executive Directors and Governors. We have an ongoing plan in relation to falls and falls risk in all relevant areas of the Trust and did so at the time of this sad incident involving Mr Mallett but wish to advise that this plan is subject to upgrading, modification and re-appraisal at regular intervals and also at any time when an incident like this prompts a re-look. ████████ commenced in post as our new Medical Director this month and I have discussed this case with him to ensure learning from this event is shared with the medical teams.”

Source location
2017-0075-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn-NHS-Trust
Page 1 · response
Published 24 March 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
Run the falls campaign and continue staff work to improve awareness of the falls assessment process.

Verbatim wording from the response
“• A falls campaign was launched on 26th January 2017 and work is on-going with the sisters, charge nurses and matrons to ensure clinical staff are fully aware of the falls assessment process.”

Source location
2017-0075-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn-NHS-Trust
Page 1 · response
Published 24 March 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
Continue ward training on assessing patients at risk of falls.

Verbatim wording from the response
“• Training is on-going on Windsor ward by the falls co-ordinator on the assessment of patients who may be at risk of falls and falls champion have been identified on the ward.”

Source location
2017-0075-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn-NHS-Trust
Page 1 · response
Published 24 March 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
Identify falls champions on Windsor ward.

Verbatim wording from the response
“• Training is on-going on Windsor ward by the falls co-ordinator on the assessment of patients who may be at risk of falls and falls champion have been identified on the ward.”

Source location
2017-0075-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn-NHS-Trust
Page 1 · response
Published 24 March 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
Pilot the bed-rails assessment document, require daily completion, and assess compliance and effectiveness before any Trust-wide rollout.

Verbatim wording from the response
“• Windsor ward piloted a newly devised bed rails assessment document in March 2017. This is to be completed every 24 hours and audits are planned to assess compliance at the end of April 2017 and the effectiveness of the tool prior to a Trust roll out.”

Source location
2017-0075-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn-NHS-Trust
Page 1 · response
Published 24 March 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
Establish an intranet site containing resources for safe falls assessment.

Verbatim wording from the response
“• The falls intranet site has been set up with all the resources required to support the safe assessment of patients in relation to falls.”

Source location
2017-0075-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn-NHS-Trust
Page 1 · response
Published 24 March 2017
Open published response
14 Feb2017
Brighton and Hove
Concerns raised1
1. Failure to incorporate family information into falls risk assessment
This report raised 25 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

Derek LEE · 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

Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

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 incorporate family information into falls risk assessment
Wider context from the report
“(3) His Falls Risk Assessment was flawed in that it failed to take into account information from his wife and son as to how he was mobilising at home. Mobilisation in Mr Lee’s case should have been at the core of the Care Plan because he was suffering from Parkinson’s Disease, where if possible, it is important to maintain mobility. Brunswick Ward should know that. ”
Source location
Derek LEE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
13 Feb2017
Birmingham and Solihull
Concerns raised1
1. Failure to place fall sensor mats on a hard floor
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 team practice for issuing sensor-mat advice and training, confirming it is consistent and accurate.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
2. Action
  Develop and send care-home guidance outlining good practice in using sensor mats for borough-wide circulation.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
Respondent positions 2
1. Position
  The team’s standard guidance did not recommend placing sensor mats on crash mats; the care home appears to have misinterpreted it.
  Stated by University Hospitals Birmingham NHS Foundation TrustDisputes the concern
1. Position
  Unable to describe measures implemented after 1 March 2017 because it will no longer manage the Home.
  Stated by Sunrise Senior Living LimitedUnable to act
AI-generated summary

Roger Harold Tombs · 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

Roger Harold Tombs died at Queen Elizabeth Hospital on 4 May 2016 after being admitted following a fall at Sunrise Care Home. He had a history of learning disabilities and an increasing risk of falls; the medical cause of death included bronchopneumonia and severe traumatic brain injury. Concerns included the failure of fall sensor mats to sound an alert and the practice of placing them on top of crash mats, which may reduce their effectiveness.

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 place fall sensor mats on a hard floor
Wider context from the report
“2. The instructions for use of the sensor mats state they should be placed on a hard floor. 3. The investigating police officer from the public protection unit gave evidence that she was concerned that the crash mats below the sensor mats would reduce the effectiveness of the sensor mats and this could possibly be the reason the mat didn’t sound (there were other possible explanations). 4. The evidence was that Sunrise of Knowle is still placing sensor mats on top of crash mats. 5. No expert opinion has been sought on this practice but the evidence of the investigating police officer was that the managing director of the local distributors of the mats told her this was an unsafe practice in his view. 6. It is my opinion that there is a risk that the effectiveness of the sensor mats is being reduced by placing them on crash mats and if this is the case they may not sound when vulnerable residents are mobilising especially when there is a risk of falls, injury and potentially death. ”
Source location
Roger Harold Tombs · 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
Review team practice for issuing sensor-mat advice and training, confirming it is consistent and accurate.

Verbatim wording from the response
“As we are concerned to hear that Sunrise Care Home are still using the sensor mats incorrectly, and as a direct result of the issuing of the PFD Report, I have reviewed practice within the team in”

Source location
Roger-Tombs-Response
Page 1 · response
Published 26 February 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 send care-home guidance outlining good practice in using sensor mats for borough-wide circulation.

Verbatim wording from the response
“Furthermore, to support the dissemination of this across the care home sector, a guidance document has been developed outlining good practice in the use of sensor mats and is enclosed for your reference. This was sent on 4 April 2017 to Theresa Scragg - Acting Strategic Commissioner for Older People, Solihull Metropolitan Borough Council (SMBC), for circulation throughout all care homes in the borough.”

Source location
Roger-Tombs-Response
Page 2 · response
Published 26 February 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
The team’s standard guidance did not recommend placing sensor mats on crash mats; the care home appears to have misinterpreted it.

Verbatim wording from the response
“The Nurse Lead informed Ms Vaughan that neither she nor any other member of the team had been directly involved with the Mr Tombs’ care, and that the advice that had been provided to Sunrise was standard guidance on the appropriate use of crash mats and sensors. It was confirmed to Ms Vaughan that the standard guidance and training would not have advocated the use of the sensor mats being placed on top of crash mats. It can be only assumed that Sunrise Care Home have misinterpreted the advice provided by the Fall Team which is supplemented by the recommendation that each resident would also need a holistic risk assessment to ensure measures could be put in place to meet each individual’s need.”

Source location
Roger-Tombs-Response
Page 1 · response
Published 26 February 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
Unable to describe measures implemented after 1 March 2017 because it will no longer manage the Home.

Verbatim wording from the response
“It is expected that SSL will be leaving the Home and will be deregistered by CQC on 1 March 2017, with another provider coming in to manage the Home and who will be registered with CQC. SOK remains registered with the CQC.”

Source location
2017-0027-Response-by-Sunrise-Senior-Living
Page 1 · response
Published 26 February 2017
Open published response
28 Dec2016
Cornwall and Isles of Scilly
Concerns raised1
1. Lack of natural barriers at the edge of the cliff at Hells Mouth
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.
Respondent positions 1
1. Position
  Vegetation cannot feasibly prevent cliff-edge access and could encourage visitors into more dangerous positions, increasing accidental trip and fall risks.
  Stated by The National Trust For Places Of Historic Interest Or Natural BeautyUnable to act
AI-generated summary

SIMON DENNIS CHARLES · 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

Simon Charles was found dead in the sea at Hells Mouth on 3 July 2016 after a concern for welfare search. He had been suffering from depression and had previously made a serious attempt to take his own life. Concerns were raised about the lack of additional preventive measures at Hells Mouth, including suicide-support signage and natural barriers.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of natural barriers at the edge of the cliff at Hells Mouth
Wider context from the report
“The Family and others at inquest raised concerns that there are not more preventive measures (apart from a fence) to those contemplating suicide (or undertaking risky behaviour) at Hells Mouth, which is a renowned suicide location in Cornwall. They provided examples of the type of measures which they felt could additionally be put in place such as: • Providing the telephone number of suicide support agencies such as the Samaritans in the same way as at Beachy Head, East Sussex • Using natural barriers at the edge of the cliff such as encouraging or planting gorse or other such plants as in Devon along the coast line especially where falls have been known to have occurred The coastline around Cornwall and in particular, the area around Hells Mouth are owned by the National Trust. It would require the consent of the National Trust to put up such signs or other preventative measures and this is the reason for raising the concerns with you and your organisation. ”
Source location
SIMON DENNIS CHARLES · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Vegetation cannot feasibly prevent cliff-edge access and could encourage visitors into more dangerous positions, increasing accidental trip and fall risks.

Verbatim wording from the response
“With regards to the suggestion that vegetation could be planted to prevent access to the cliff edge, we believe this would be difficult to achieve and counterproductive. The exposed nature of the cliff top in this area limits the natural growth of shrubs and we feel it would not be possible to establish sufficient growth to prevent physical access to the cliff. The impact on the views that screening by vegetation would produce would, in our view, encourage visitors to circumvent such a barrier and put themselves in a potentially much more dangerous position, leading to a greater chance of accidental trips and falls.”

Source location
2016-0465-Response-by-National-Trust.pdf
Page 1 · response
Published 28 December 2016
Open published response
28 Dec2016
Cornwall and Isles of Scilly
Concerns raised1
1. Lack of formal protocols for notifying district nurses of falls or changes in fall risk
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.

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

Dorothea Jean Parr · 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

Dorothea Parr fell from a newly delivered electric riser-recliner chair at home on 21 March 2016, sustained a fractured neck of femur, and died of pneumonia on 28 March 2016. The report raised concerns that the chair was delivered without notifying her family, carers, or district nurses, limiting opportunities for training and risk assessment. It also identified a lack of formal procedures for notifying district nurses about falls, changes in presentation, or new equipment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of formal protocols for notifying district nurses of falls or changes in fall risk
Wider context from the report
“The District Nurse Manger explained that it was the role of the District Nurses to carry out the Falls Risk Assessment for clients living in the community at risk of falling. The District Nurses were very dependent on other agencies to inform them of falls or changes to the risk of falls e.g. the delivery of the electric chair or changes in presentation which increase the risk of falls e.g. confusion. In this case District nurses were not informed of the fall on 21st March from the new electric chair and no requirement for this to be done and so there was a lost opportunity to provide input – which in this case could have been to deactivate the electric armchair while the carers were not present. Although there were informal procedures in place for district nurse notification, there were no formal protocols or procedures in place. ”
Source location
Dorothea Jean Parr · Prevention of Future Deaths report
Page 1 · concerns
Open source report
21 Dec2016
South Wales Central
Concerns raised3
1. Lack of comprehensive transfer handover of falls risk
2. Failure to integrate and respond to the whole picture of ongoing falls risk
3. Inaccurate and incomplete nursing notes and falls records
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
  Introduce National Patient Safety Agency falls risk assessments.
  Stated by Swansea Bay University Local Health BoardStated completed
2. Action
  Continue Falls Management Group scrutiny of training, individual falls reviews and performance data.
  Stated by Swansea Bay University Local Health BoardStated in progress
Respondent positions 1
1. Position
  Falls management is devolved to directly managed units, while the Falls Management Group retains scrutiny and performance-review functions.
  Stated by Swansea Bay University Local Health BoardRedirects responsibility
AI-generated summary

David Bassett COOPER · 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

David Bassett Cooper was admitted to hospital after a serious head injury caused by a fall in the community and sustained nine further falls while being transferred between wards. He died from a subdural haematoma caused by the final fall on 5 March 2016. The concerns included inadequate handovers about falls risk, incomplete nursing records, a failure to see the overall pattern of falls, and shortcomings in arranging additional one-to-one nursing care.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of comprehensive transfer handover of falls risk
Wider context from the report
“1. When transfers between wards took place, the evidence revealed that there was a lack of comprehensive hand-over by the transferring ward to the receiving ward especially in terms of identifying the patient’s risk of falls. For example, on ward 18 Mr Cooper was in receipt of ‘1:1’ nursing care, but on transfer to ward 21, not only was that never given, but the evidence suggested it was not considered. ”
Source location
David Bassett COOPER · Prevention of Future Deaths report
Page 1 · 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 integrate and respond to the whole picture of ongoing falls risk
Wider context from the report
“3. The evidence revealed that there was a distinct lack of “joined up” thinking and a failure to see the “whole picture”. Mr Cooper’s risk of falling was as high when he was admitted in October 2015 as it was when he died in March 2016, but still he sustained 9 falls. ”
Source location
David Bassett COOPER · Prevention of Future Deaths report
Page 1 · 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 and incomplete nursing notes and falls records
Wider context from the report
“2. The accuracy and completeness of nursing notes and records left much to be desired. For example, on Ward 21 when he fell three times, there was no entry made in the Falls Diary – a document which was supposed to act as a tool for nursing staff to assess whether there was a pattern to the numerous falls being sustained – save for the last fall on 5th March. This deprived staff of the opportunity to see the ‘whole picture’ and to take into consideration the eight falls which he had sustained up to that point. ”
Source location
David Bassett COOPER · 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
Introduce National Patient Safety Agency falls risk assessments.

Verbatim wording from the response
“The Health Board established a Falls Management Group in September 2015. This was a task and finish group that reviewed policies and training requirements in relation to falls management. The Health Board introduced the National Patient Safety Agency’s Risk Assessments and I enclose the Health Board’s Falls Policy and other supporting information for your review. The Falls Management Group last met in December 2016 and devolved falls management to the Directly Managed Units to ensure clinical orientation and responsibility.”

Source location
2016-0459-Response-by-University-Health-Board
Page 1 · response
Published 12 February 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
Continue Falls Management Group scrutiny of training, individual falls reviews and performance data.

Verbatim wording from the response
“The Falls Management Group will continue to meet as a scrutiny panel to ensure that appropriate training and individual falls scrutiny is being undertaken along with continued review of performance data. ████████ Consultant Physician and Geriatrician, will be leading the Falls Management Group.”

Source location
2016-0459-Response-by-University-Health-Board
Page 1 · response
Published 12 February 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
Falls management is devolved to directly managed units, while the Falls Management Group retains scrutiny and performance-review functions.

Verbatim wording from the response
“The Health Board established a Falls Management Group in September 2015. This was a task and finish group that reviewed policies and training requirements in relation to falls management. The Health Board introduced the National Patient Safety Agency’s Risk Assessments and I enclose the Health Board’s Falls Policy and other supporting information for your review. The Falls Management Group last met in December 2016 and devolved falls management to the Directly Managed Units to ensure clinical orientation and responsibility.”

Source location
2016-0459-Response-by-University-Health-Board
Page 1 · response
Published 12 February 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Unavailability of falls sensors for patients assessed at risk of falls

Concerns raised2

Failure to offer analgesia to residents reporting pain after a fall

Failure to make the falls protocol clearly available to staff

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

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

Concerns raised2

Inaccurate falls-risk documentation

Lack of understanding of reviews and required post-fall processes

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.4

Concerns raised1

Reliance on reactive rather than proactive falls prevention

Concerns raised2

Absence of falls planning and prevention

Failure to use available movement-alert and fall-prevention equipment

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.6

Concerns raised1

Failure to incorporate family information into falls risk assessment

Concerns raised1

Failure to place fall sensor mats on a hard floor

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 1

Respondent positions 1

Actions described in response 4

Actions described in response 6

Actions described in response 2

Respondent positions 2