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
Distinct published reports
Individual concerns
285
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
349
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.
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
NHS trust65
Healthcare site22
Residential care home21
Nursing home19
Private limited company16
Ministerial department14
Type not available11
Health and social care service regulator9
Local health board9
English metropolitan district council7
Multi-service care provider7
Care-home operator5
Coronial office5
English county council5
Executive non-departmental public body4
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.
Birmingham and Solihull
Concerns raised2
Failure of documentation on other forms to prompt reconsideration of the falls risk assessment
Failure of the falls risk assessment document to prompt assessment of attachment relevance
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Review the falls risk assessment and identify required improvements to capture equipment-related mobility risks.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2023.
Action
Add a PICS falls-assessment dropdown for equipment such as drains and record the selected information in the Patient Handling Assessment Form.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 May 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Manual handling and falls assessments need not automatically feed into each other because staff are expected to consider them together with other records.
Stated by University Hospitals Birmingham NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure to complete Falls Risk Assessments accurately
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Recirculate the falls proforma within the Acute Medical Unit and implement monthly ward-link-nurse audits of assessment accuracy.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
Action
Amend the falls-prevention policy to assess changes from a patient’s baseline mobility and support holistic patient and relative or carer assessment.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2023.
Action
Operate the Safer Care Group to develop, implement and monitor falls-prevention work, including training, audit, performance gaps and improvement plans.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
Essex
Concerns raised2
Delays in completing falls risk assessments
Inaccurate falls risk assessments and updates
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.
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
Action
Complete falls assessments within 24 hours of admission and update them after clinical changes.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2023.
Action
Include falls-risk assessment training in clinical and temporary-worker induction, with probationary knowledge review for substantive staff.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2023.
Action
Audit falls-risk assessment completion weekly and monitor outstanding assessments through ward dashboards, handovers and assurance processes.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2023.
Action
Relauch ward Falls Champion Networks to share learning, support revised policy implementation and audit updated falls assessments.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 March 2023.
Worcestershire
Concerns raised2
Failure to consider measures to mitigate residents’ increased falls risk
Failure to update residents’ falls risk assessment and care plan documentation following 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Amend monthly clinical governance meetings to review each resident’s falls and falls history.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 14 April 2023.
Action
Introduce a regional falls champion forum chaired by divisional clinical lead nurses.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 14 April 2023.
Action
Update the organisational Falls Management Policy and share the update with Latimer Court’s senior care team.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 14 April 2023.
Action
Develop and introduce a Post Falls Assessment Tool covering injury assessment, observations and escalation.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 14 April 2023.
Action
Deliver refresher training at Latimer Court on the Falls Management Policy and post-fall risk-review procedures.
Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 14 April 2023.
Action
Develop Latimer Court checklists or prompts with the Clinical Development Nurse in line with the Falls Management Policy.
Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 14 April 2023.
Action
Deliver refresher training at Latimer Court on completing documentation, including risk-related detail and timely updates.
Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 14 April 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The identified practice matters were unlikely to have affected the resident’s outcome.
Stated by Barchester Healthcare LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Hampshire, Portsmouth and Southampton
Concerns raised1
Failure to update nursing care plan risk assessments in response to changes in clinical presentation and falls
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Continue ward accreditation assessments, including care-plan and patient-record reviews, feedback, action planning and governance reporting.
Stated by Portsmouth Hospitals University NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing ward accreditation and clinical audit processes are considered sufficient to address nursing documentation and care-plan completion concerns.
Stated by Portsmouth Hospitals University NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Failure to prevent falls among high-risk hospital patients
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Seek assurance from Trust leadership that patient-safety changes address fall prevention and staff training for prompt action after head injuries.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 21 November 2022.
Hampshire, Portsmouth and Southampton
Concerns raised1
Insufficient measures to prevent deaths from jumping from bridges
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Engage specialist teams and agencies to assess whether interventions are warranted when similar risks are identified on County Council highway bridges.
Stated by Hampshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 20 October 2022.
Action
Add the location to the South East Network Needs list for future funding prioritisation.
Stated by National HighwaysStated completedThe respondent said that this action was complete when they made their response on 20 October 2022.
Action
Apply for future funding for a study into preventing future suicide events at the location.
Stated by National HighwaysStated plannedThe respondent said that this action was planned when they made their response on 20 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
National Highways, as bridge asset owner, must essentially consider the required action, while the County Council can collaborate on potential solutions.
Stated by Hampshire County CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The existing 1.65-metre parapet complies with current standards, and enclosing the walkway is not considered appropriate because enclosed spaces can increase antisocial behaviour.
Stated by National HighwaysExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Further measures, including CCTV or physical barriers, depend on a funded study establishing their suitability and securing future funding.
Stated by National HighwaysUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised2
Inconsistent use of bed signs to identify falls risk to staff
Delays in completing falls-risk assessments after transfer to a new ward
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Relaunch the maple leaf sign requirement across the Trust through weekly bulletin and targeted governance-team emails.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2022.
Action
Add maple leaf sign use to agency staff induction checklists.
Stated by Stockport NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The six-hour assessment standard is retained because it allows admission and accurate documentation, while formal handover provides immediate risk communication.
Stated by Stockport NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Dorset
Concerns raised1
Failure to complete and record 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Upload the post-falls assessment tool to the electronic recording system for staff use and recording.
Stated by Tricuro LtdStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Action
Disseminate the updated falls policy across the service and wider company, including requirements to update risk assessments and mobility care plans after falls.
Stated by Tricuro LtdStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Avon
Concerns raised1
Failure to allocate the appropriate ECO observation level following falls risk assessment
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Implement the revised Enhanced Care Observation and Meaningful Activities Policy with non-numbered observation categories and holistic patient-needs guidance.
Stated by Bristol NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Action
Strengthen the Enhanced Care Observation policy with North Bristol NHS Trust partners.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 September 2022.
Action
Provide affected staff groups with support, education, training, ward signs, meaningful-activities resources and task kits after policy approval.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The patient’s admission presentation did not trigger higher observation because he was calm, oriented, engaged, and able to follow instructions.
Stated by Bristol NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Pin
Get email alerts
Request correction
Includes assessment, care planning, equipment, supervision, handover, referral, reporting, post-fall response and assurance explicitly dedicated to falls risk.
