Recurring concern

Inadequate control of falls risks

First to latest report 31 Oct 2013 — 21 May 2026

Reports that mention this concern: 165
Times this concern has been raised: 285
Stated actions linked to this concern: 349

What this concern includes

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

What is 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

Trends

Reports over time

Reports mentioning this concern, 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

Reports and published responses 165 reports

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

1 Jul2022
Sefton St Helens & Knowsley
Concerns raised1
1. Lack of falls assessment and care planning
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Joan RICHARDSON · 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

Joan RICHARDSON, a frail 98-year-old woman living in supported accommodation, became increasingly unwell at home and was admitted to hospital on 4 May 2020. She had pneumonia, a fractured neck of femur and grade 4 sacral pressure wounds, and died in hospital on 18 May 2020. Concerns included failures to escalate her deterioration and pain, incomplete care planning and risk assessments, inadequate pressure-area care and documentation, and inadequate staff training and escalation procedures.

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 falls assessment and care planning
Wider context from the report
“(brief summary of matters of concern) Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;- 1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc. 2. When Joan complained of pain -the matter was not escalated as it should have been. 3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital. 4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment. 5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly. 6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required. ”
Source location
Joan RICHARDSON · Prevention of Future Deaths report
Page 3 · concerns
Open source report
3 Mar2022
Gwent
Concerns raised2
1. Failure to complete Multifactorial Risk Assessments at admission and after hospital transfers or falls
2. Failure to complete regular ward audits of falls risk assessments
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Marvin John RUE · 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

Marvin Rue was admitted to hospital on 8 January 2021 after a fall and fell five times during his admission. On 2 February 2021, he suffered a fatal head injury after another fall and died on 3 February 2021. The principal concerns were failures to complete falls-risk assessments after admission, hospital transfers and previous falls, resulting in inadequate supervision; the report also identified failures to investigate staff non-compliance and to carry out audits.

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 Multifactorial Risk Assessments at admission and after hospital transfers or falls
Wider context from the report
“Marvin Rue had fallen prior to his admission to hospital on 8th January 2021 and was therefore, due to his age and circumstances, a “known falls risk”. In evidence I heard that in these circumstances a Multifactorial Risk Assessment (MFRA) should take place within 6 hours of admission to hospital. It was not. Mr Rue was transferred between hospitals during his admission, initially to Nevill Hall Hospital and then to Ysbyty Aneurin Bevan. I heard in evidence that a review of the MFRA should take place after every hospital transfer. Mr Rue had no MFRA undertaken after his transfers. Mr Rue fell 5 times prior to his fatal fall in hospital on 2nd February 2021. Contrary to Health Board Policy, Mr Rue did not have an MFRA undertaken after any of these falls. In fact there was never an MFRA correctly completed for Mr Rue throughout his hospital admission. I heard evidence that during this time the staff were under significant pressure due to the effects of the pandemic, and I accept that. However the care that Mr Rue was denied was basic nursing care. ████████ the Lead Nurse and author of the Serious Concerns Report, indicated that had Mr Rue been assessed, he would have warranted 1:1 supervision . As a result I concluded that the failures in care directly contributed to Mr Rue’s death. During the inquest I have been presented with an action plan, however this is not the first action plan I have been presented with (in very similar circumstances) and sadly I am not convinced that this plan will prevent future deaths for the following reasons. The policies referred to above have been in place for several years. I am informed that although there is bespoke documentation training, all staff are trained in falls risk assessment from the time they are in nurse training. Therefore it is not a lack of understanding or policies which have caused these failures. None of the staff were interviewed during the internal investigation and no evidence was forthcoming as to why staff did not follow the procedures. Without this information I do not consider that the actions plan will prevent future deaths. I refer you to your previous responses to PFDs which have clearly not had the desired outcome. Despite being previously reassured that regular ward audits would take place to ensure that the risk assessment were being undertaken I heard no evidence that audits were completed at this time and so the failures went unnoticed until after Mr Rue’s death. ”
Source location
Marvin John RUE · 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 regular ward audits of falls risk assessments
Wider context from the report
“Marvin Rue had fallen prior to his admission to hospital on 8th January 2021 and was therefore, due to his age and circumstances, a “known falls risk”. In evidence I heard that in these circumstances a Multifactorial Risk Assessment (MFRA) should take place within 6 hours of admission to hospital. It was not. Mr Rue was transferred between hospitals during his admission, initially to Nevill Hall Hospital and then to Ysbyty Aneurin Bevan. I heard in evidence that a review of the MFRA should take place after every hospital transfer. Mr Rue had no MFRA undertaken after his transfers. Mr Rue fell 5 times prior to his fatal fall in hospital on 2nd February 2021. Contrary to Health Board Policy, Mr Rue did not have an MFRA undertaken after any of these falls. In fact there was never an MFRA correctly completed for Mr Rue throughout his hospital admission. I heard evidence that during this time the staff were under significant pressure due to the effects of the pandemic, and I accept that. However the care that Mr Rue was denied was basic nursing care. ████████ the Lead Nurse and author of the Serious Concerns Report, indicated that had Mr Rue been assessed, he would have warranted 1:1 supervision . As a result I concluded that the failures in care directly contributed to Mr Rue’s death. During the inquest I have been presented with an action plan, however this is not the first action plan I have been presented with (in very similar circumstances) and sadly I am not convinced that this plan will prevent future deaths for the following reasons. The policies referred to above have been in place for several years. I am informed that although there is bespoke documentation training, all staff are trained in falls risk assessment from the time they are in nurse training. Therefore it is not a lack of understanding or policies which have caused these failures. None of the staff were interviewed during the internal investigation and no evidence was forthcoming as to why staff did not follow the procedures. Without this information I do not consider that the actions plan will prevent future deaths. I refer you to your previous responses to PFDs which have clearly not had the desired outcome. Despite being previously reassured that regular ward audits would take place to ensure that the risk assessment were being undertaken I heard no evidence that audits were completed at this time and so the failures went unnoticed until after Mr Rue’s death. ”
Source location
Marvin John RUE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Feb2022
Norfolk
Concerns raised4
1. Unavailability of an appointed Falls Lead
2. Failure to complete the Falls Risk Assessment
3. Failure of the Falls Policy to comply with NICE Guidelines
1. Failure to complete the Falls Policy
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Irene Muriel FITCHES · 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

Irene Muriel Fitches was admitted to hospital on 17 July 2021 with dizziness, nausea and general illness, and was diagnosed with Benign Positional Paroxysmal Vertigo. On 21 July 2021 she had an unwitnessed fall, suffered a head injury, deteriorated and became unresponsive; she died on 22 July 2021. The substantive concerns included a Falls Policy that did not comply with NICE Guidelines, no appointed Falls Lead, undeveloped staff training, and limited progress on assisted technology.

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 an appointed Falls Lead
Wider context from the report
“3. There is no person appointed as Falls Lead. The job application has not yet been advertised, although it is recognised that someone is required to lead the Falls process. ”
Source location
Irene Muriel FITCHES · 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 complete the Falls Risk Assessment
Wider context from the report
“2. Evidence was heard that a Falls Policy was drafted, and a Risk Assessment trialled at the beginning of 2020, the Covid-19 pandemic intervened and delayed its completion. ”
Source location
Irene Muriel FITCHES · 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 of the Falls Policy to comply with NICE Guidelines
Wider context from the report
“1. The Falls Policy does not comply with NICE Guidelines. ”
Source location
Irene Muriel FITCHES · 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 complete the Falls Policy
Wider context from the report
“2. Evidence was heard that a Falls Policy was drafted, and a Risk Assessment trialled at the beginning of 2020, the Covid-19 pandemic intervened and delayed its completion. ”
Source location
Irene Muriel FITCHES · Prevention of Future Deaths report
Page 1 · concerns
Open source report
11 Jan2022
Avon
Concerns raised2
1. Lack of documentation demonstrating post-fall review of residents’ risk assessments
2. Delays in completing post-fall risk assessment reviews
Linked response

Management Team, Blenheim House Care Home
Stated actions 1
1. Management Team, Blenheim House Care Home
  Require falls to be recorded and post-fall risk assessments completed within 24 hours, and communicate the requirement and its safety rationale to staff.
AI-generated summary

Reginald Howard Weston · 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

Reginald Howard Weston died from injuries sustained in a fall on 7 July 2021, after having fallen twice on 4 July 2021. The principal concern was that there was no evidence his falls risk assessment was reviewed and recorded as required, including a timely process for completing the review.

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 documentation demonstrating post-fall review of residents’ risk assessments
Wider context from the report
“Evidence was given in relation to the Majesticale Falls Management Policy and Procedure requirement to record a review of the resident’s risk assessment in the context of 2 recorded falls on 4 July 2021. Blenheim House management need to consider: a) Documentation demonstrating a review of the resident’s risk assessment has taken place following a fall b) Timely process for completing it ”
Source location
Reginald Howard Weston · 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
Delays in completing post-fall risk assessment reviews
Wider context from the report
“Evidence was given in relation to the Majesticale Falls Management Policy and Procedure requirement to record a review of the resident’s risk assessment in the context of 2 recorded falls on 4 July 2021. Blenheim House management need to consider: a) Documentation demonstrating a review of the resident’s risk assessment has taken place following a fall b) Timely process for completing it ”
Source location
Reginald Howard Weston · 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
Require falls to be recorded and post-fall risk assessments completed within 24 hours, and communicate the requirement and its safety rationale to staff.

Verbatim wording from the response
“2. All falls, care plans and risk assessments continue to be reviewed post fall as the position was previously; however a new timescale has been added that the fall needs to be recorded and the risk assessment needs to be completed within 24 hours of any fall. This has been communicated to staff together with an explanation as to why this data is critical in assessing a service users fall risk. A copy of the risk assessment is provided in Appendix 1 to this response.”

Source location
2022-0008-Response-from-Blenheim-House-Care-Home
Page 1 · response
Published 14 January 2022
Open published response
1 Sep2021
South London
Concerns raised1
1. Failure to complete falls risk assessments
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

King'S College Hospital NHS Foundation Trust
Stated actions 3
1. King'S College Hospital NHS Foundation Trust
  Use falls data and risk-assessment completion findings in ward teaching, nursing induction and annual clinical updates.
2. King'S College Hospital NHS Foundation Trust
  Develop Epic functionality for live monitoring of falls risk-assessment compliance and incident learning.
3. King'S College Hospital NHS Foundation Trust
  Work with the Business Intelligence Unit toward automated falls risk-assessment monitoring using electronic health records.
AI-generated summary

Hazel Fleur Wiltshire · 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

Hazel Fleur Wiltshire was admitted to hospital after a fall at home and died there on 19 February 2021 from pneumonia caused by the fall and Covid-19 acquired in hospital. Concerns included lengthy delays in responding to call bells, inadequate staffing and the absence of falls risk assessments across three wards.

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
Wider context from the report
“(3) Although Mrs Wiltshire was at risk of falls, no risk assessments were completed on any of the three wards in which she stayed. This suggests a systemic problem across the hospital that requires remedial action. ”
Source location
Hazel Fleur Wiltshire · 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
Use falls data and risk-assessment completion findings in ward teaching, nursing induction and annual clinical updates.

Verbatim wording from the response
“The Falls Team routinely review falls data, including completion of risk assessments, and this is fed into teaching sessions on the wards, induction for nursing staff and annual clinical update (described in more detail below.) We are currently working with Epic (the new Electronic Patient Record which is currently being developed for the Trust) to input learning from patient safety incidents and to ensure that the system can be used for live monitoring of risk assessment compliance to drive Trust and local improvement. The falls team are also reviewing working with the Business Intelligence Unit (BIU) to move to a more automated approach using the current patients’ electronic health records in the interim.”

Source location
Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 2021
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 Epic functionality for live monitoring of falls risk-assessment compliance and incident learning.

Verbatim wording from the response
“The Falls Team routinely review falls data, including completion of risk assessments, and this is fed into teaching sessions on the wards, induction for nursing staff and annual clinical update (described in more detail below.) We are currently working with Epic (the new Electronic Patient Record which is currently being developed for the Trust) to input learning from patient safety incidents and to ensure that the system can be used for live monitoring of risk assessment compliance to drive Trust and local improvement. The falls team are also reviewing working with the Business Intelligence Unit (BIU) to move to a more automated approach using the current patients’ electronic health records in the interim.”

Source location
Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 2021
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
Work with the Business Intelligence Unit toward automated falls risk-assessment monitoring using electronic health records.

Verbatim wording from the response
“The Falls Team routinely review falls data, including completion of risk assessments, and this is fed into teaching sessions on the wards, induction for nursing staff and annual clinical update (described in more detail below.) We are currently working with Epic (the new Electronic Patient Record which is currently being developed for the Trust) to input learning from patient safety incidents and to ensure that the system can be used for live monitoring of risk assessment compliance to drive Trust and local improvement. The falls team are also reviewing working with the Business Intelligence Unit (BIU) to move to a more automated approach using the current patients’ electronic health records in the interim.”

Source location
Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 2021
Open published response
26 Jul2021
North Wales (East and Central)
Concerns raised1
1. Failure to implement falls risk measures consistently and effectively
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Hillbury & Gwern Alyn
Stated actions 2
1. Hillbury & Gwern Alyn
  Continue using the North Wales falls pathway with GPs and health professionals for residents with a history of falls or new falls.
2. Hillbury & Gwern Alyn
  Maintain relevant falls management documents within residents’ care plans, including risk assessments, accident records and post-fall reports.
Respondent positions 2
1. Hillbury & Gwern Alyn
  Existing falls assessments, reviews, clinical input and the falls pathway were considered sufficient; no additional mobility or falls-management support was identified.
  Existing arrangements considered sufficient
1. Hillbury & Gwern Alyn
  Completely eliminating falls risk was considered unrealistic and unachievable for an older person with capacity and freedom to choose movement.
  Disputes the concern
AI-generated summary

Albert Rowlands · 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

Albert Rowlands suffered serious injuries in an unwitnessed accidental fall at the residential care home where he lived and died in hospital on 25 November 2020. The principal concerns were inconsistent implementation of falls-prevention measures, possible staffing pressures affecting care, and the risks associated with the distance and obstacles between his room and the nearest toilet.

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 implement falls risk measures consistently and effectively
Wider context from the report
“1. Despite the care home having identified the risks associated with Mr Rowlands wandering unsupervised and falling, the control measures put in place (including Zimmer frame use and the bedside pressure mat), these did not eliminate the risk. Mr Rowlands (on the occasion of this accident and at other times) was plainly able to get out of bed without his alarm sounding, and to move around without always using his Zimmer frame. I believe that care home should consider whether more can be done to ensure that falls risk measures are implemented consistently, as intended, and to identify additional steps that could be taken to reduce the risks to residents such as Mr Rowlands. ”
Source location
Albert Rowlands · 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
Continue using the North Wales falls pathway with GPs and health professionals for residents with a history of falls or new falls.

Verbatim wording from the response
“Having moved into Gwern Alyn, he was supported by staff being available 24 hours a day and was placed on a “North Wales Prevention and Management of Falls in Care homes falls pathway”.”

Source location
2021-0253-Response-from-Pendine-Park_Published
Page 1 · response
Published 3 August 2021
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
Maintain relevant falls management documents within residents’ care plans, including risk assessments, accident records and post-fall reports.

Verbatim wording from the response
“3 We will continue to ensure that within the care plan that staff utilise and maintain the relevant falls management documents as follows:”

Source location
2021-0253-Response-from-Pendine-Park_Published
Page 4 · response
Published 3 August 2021
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 falls assessments, reviews, clinical input and the falls pathway were considered sufficient; no additional mobility or falls-management support was identified.

Verbatim wording from the response
“Having moved into Gwern Alyn, he was supported by staff being available 24 hours a day and was placed on a “North Wales Prevention and Management of Falls in Care homes falls pathway”.”

Source location
2021-0253-Response-from-Pendine-Park_Published
Page 1 · response
Published 3 August 2021
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
Completely eliminating falls risk was considered unrealistic and unachievable for an older person with capacity and freedom to choose movement.

Verbatim wording from the response
“In relation to the comment made that the home had not “eliminated the falls risk”, for Mr Rowlands, we respectfully submit that this is an unrealistic and unachievable aim, in an elderly person, with capacity to make choices about movement and not subjected to DOLS, where ‘The person is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements.’”

Source location
2021-0253-Response-from-Pendine-Park_Published
Page 2 · response
Published 3 August 2021
Open published response
8 Jul2021
Newcastle Upon Tyne and North Tyneside
Concerns raised2
1. Failure to maintain observational charts for patients at risk of falls
2. Failure to document daily and post-change falls-risk reassessments
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Northumbria Healthcare NHS Foundation Trust
Stated actions 2
1. Northumbria Healthcare NHS Foundation Trust
  Implement a ward observation chart specifying enhanced-observation levels and required frequencies.
2. Northumbria Healthcare NHS Foundation Trust
  Place the AFLOAT assessment and observation chart into the NerveCentre electronic care record, with mandatory daily registered-nurse review.
Respondent positions 1
1. Northumbria Healthcare NHS Foundation Trust
  Existing observation charts, safety huddles, AFLOAT use and planned electronic alerts sufficiently reduce the risk of similar incidents, making further PFD action disproportionate.
  Existing arrangements considered sufficient
AI-generated summary

Benjamin Clark · 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

Benjamin Clark died in hospital on 17 January 2021 after a series of falls, including an unwitnessed fall on the ward, resulting in Acute on Chronic Subdural Haematomas. The concerns included an undocumented downgrading of his falls-risk assessment, unclear observation requirements, suboptimal record keeping, lack of observational charts, and insufficient written evidence of daily reassessment or reassessment after significant changes.

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 maintain observational charts for patients at risk of falls
Wider context from the report
“3. The Avoiding Falls Level of Observation Assessment Tool (AFLOAT) was used in both hospitals but only NSECH evidenced use of this tool in writing. Observational charts were not in use in North Tyneside General Hospital. Matron ████████ told me that every patient should be reassessed every day and following any significant change in presentation. There was a lack of written evidence at North Tyneside General Hospital to demonstrate that this had been done in Mr. Clark’s case. ”
Source location
Benjamin Clark · 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 document daily and post-change falls-risk reassessments
Wider context from the report
“3. The Avoiding Falls Level of Observation Assessment Tool (AFLOAT) was used in both hospitals but only NSECH evidenced use of this tool in writing. Observational charts were not in use in North Tyneside General Hospital. Matron ████████ told me that every patient should be reassessed every day and following any significant change in presentation. There was a lack of written evidence at North Tyneside General Hospital to demonstrate that this had been done in Mr. Clark’s case. ”
Source location
Benjamin Clark · 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 a ward observation chart specifying enhanced-observation levels and required frequencies.

Verbatim wording from the response
“1. Since the incident involving Mr Clark, the ward at NTGH have now implemented a new observation chart. This chart determines the frequency that observations should be taken on the front of the chart. The reverse of the chart is set out differently to the standard observations chart to allow for increased frequency observations to be completed. A copy of this observation chart was shared with the family and HM Assistant Coroner on the day of the inquest. It was confirmed that the use of this chart was a pilot and is well used within NSECH and had also been adopted by NTGH.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 2021
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
Place the AFLOAT assessment and observation chart into the NerveCentre electronic care record, with mandatory daily registered-nurse review.

Verbatim wording from the response
“4. Discussions are ongoing between the Matrons within NTGH in order to place the AFLOAT risk assessment and observation chart onto the electronic care record NerveCentre. The Trust can confirm that this will be done before the end of August 2021. Notwithstanding this, the documents are in use in paper form.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 2021
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 observation charts, safety huddles, AFLOAT use and planned electronic alerts sufficiently reduce the risk of similar incidents, making further PFD action disproportionate.

Verbatim wording from the response
“1. Since the incident involving Mr Clark, the ward at NTGH have now implemented a new observation chart. This chart determines the frequency that observations should be taken on the front of the chart. The reverse of the chart is set out differently to the standard observations chart to allow for increased frequency observations to be completed. A copy of this observation chart was shared with the family and HM Assistant Coroner on the day of the inquest. It was confirmed that the use of this chart was a pilot and is well used within NSECH and had also been adopted by NTGH.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 2021
Open published response
2 Jun2021
Black Country
Concerns raised2
1. Failure to undertake falls risk assessments for vulnerable and elderly A&E patients during prolonged stays
2. Lack of national guidelines for falls risk assessments in A&E departments
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

National Institute for Health and Care Excellence
Stated actions 1
1. National Institute for Health and Care Excellence
  Update CG161 while considering issues raised in the report during scoping.
AI-generated summary

GEOFFREY WILLIAM HILL · 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

Geoffrey William Hill, aged 82, was admitted to hospital with Covid-19, reduced mobility and general illness, and fell from a trolley bed in the emergency department, sustaining a head injury. He later became unresponsive and died in hospital from a traumatic subdural haemorrhage. Concerns included the absence of a falls risk assessment, trolley rail assessment, advanced observations, mental test and therapy assessment, and the broader lack of national guidance for falls prevention in emergency departments.

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 falls risk assessments for vulnerable and elderly A&E patients during prolonged stays
Wider context from the report
“(7) I am concerned that vulnerable and elderly patients in A & E can spend long periods without any falls risk assessments being undertaken placing them at risk. ”
Source location
GEOFFREY WILLIAM HILL · 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 national guidelines for falls risk assessments in A&E departments
Wider context from the report
“(2) The inquest heard in evidence that there were no national guidelines on the use of falls risk assessments in A & E departments; (3) The inquest heard in evidence there was no national requirements or guidance for a trolley rail assessment to be completed in A & E; (4) As Mr Hill did not present with a fall or recurrent falls there was no requirement for any generic or multi factorial risk assessment to be conducted; ”
Source location
GEOFFREY WILLIAM HILL · 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
Update CG161 while considering issues raised in the report during scoping.

Verbatim wording from the response
“We are about to update CG161 and the issues raised in your report will be considered as we scope out what needs to be considered in the update.”

Source location
2021-0262-Response-from-NICE_Published
Page 1 · response
Published 9 August 2021
Open published response
24 May2021
Manchester West
Concerns raised1
1. Failure to trigger serious or untoward incident review following repeated falls
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

KENNETH SMITH · 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 Smith, who had cognitive impairment and was at high risk of falls, died on 9 November 2020 after falling at a care home and developing acute-on-chronic subdural haematomas. The report raised concerns about reducing his supervision, failing to set a review date, inadequate escalation of care after further falls, and insufficient consideration of medication and mental-health factors in assessing his falls risk.

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 trigger serious or untoward incident review following repeated falls
Wider context from the report
“After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020. Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered. The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury. Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all. Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020. The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns: 1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful. 2. The failure to consider and specify a review date; 3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review. 4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority; ”
Source location
KENNETH SMITH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
4 May2021
Shropshire, Telford and Wrekin
Concerns raised1
1. Failure to ensure porters know patients’ falls risk
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

the Shrewsbury and Telford Hospital NHS Trust
Stated actions 2
1. the Shrewsbury and Telford Hospital NHS Trust
  Deliver falls-awareness training to Portering staff, including recognition of visual fall-risk alerts, with induction and three-yearly refresher delivery.
2. the Shrewsbury and Telford Hospital NHS Trust
  Include mandatory falls-awareness training expectations for Porters in the Procedure for Managing Inpatient Falls.
AI-generated summary

William Arthur John SIMONS · 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

William Arthur John SIMONS died following two falls while receiving treatment at Royal Shrewsbury Hospital, with the second fall identified as more significant and preventable. Concerns included confusion and communication failures in the Tele-tracking transport system, unclear responsibilities when nursing staff were unavailable to assist a patient, and inadequate awareness of the patient's falls risk.

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 porters know patients’ falls risk
Wider context from the report
“(1) The Tele-tracking system a) It was not clear what the purpose was of a doctor expressing a preferred option of transport (i.e. by trolley/bed) if that doctor did not have sufficient information to make it. b) Whilst it became clear that that option was subject to review by the nursing staff on the ward it was not clear why a doctor would not either liaise with the nursing staff or expressly make it clear that the nursing staff should make that assessment and inform the porters accordingly. c) The system on the day led to confusion and a breakdown in communication with the patient being taken instead by wheelchair with his zimmer frame. (2) Assistance. It was established that assisting a patient to move meant by a member of the nursing staff and not a porter. It should be clear what a porter is to do if no nursing staff is available. (3) Risk awareness. The porter did not know the patient’s level of risk of falls. ”
Source location
William Arthur John SIMONS · 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 falls-awareness training to Portering staff, including recognition of visual fall-risk alerts, with induction and three-yearly refresher delivery.

Verbatim wording from the response
“Falls awareness training is currently being delivered by the Falls Practitioner to all Portering staff. This training includes making Porters aware of visual alerts that patients at risk of falls have in place, for example yellow wrist bands and icons both at their bed space and on the patient safety screens near the nurses’ station. The expectations around undertaking falls awareness training for Porters will be included in the Procedure for Managing Inpatient Falls. This training will now be delivered to Portering staff on induction and 3 yearly as part of statutory mandatory training for Porters. The training, in combination with a clear briefing from the Registered Nurse to the Porter transferring the patient, should ensure the Porter is aware of the individual risk for the patient being transferred.”

Source location
2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
Page 3 · response
Published 5 May 2021
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
Include mandatory falls-awareness training expectations for Porters in the Procedure for Managing Inpatient Falls.

Verbatim wording from the response
“Falls awareness training is currently being delivered by the Falls Practitioner to all Portering staff. This training includes making Porters aware of visual alerts that patients at risk of falls have in place, for example yellow wrist bands and icons both at their bed space and on the patient safety screens near the nurses’ station. The expectations around undertaking falls awareness training for Porters will be included in the Procedure for Managing Inpatient Falls. This training will now be delivered to Portering staff on induction and 3 yearly as part of statutory mandatory training for Porters. The training, in combination with a clear briefing from the Registered Nurse to the Porter transferring the patient, should ensure the Porter is aware of the individual risk for the patient being transferred.”

Source location
2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
Page 3 · response
Published 5 May 2021
Open published response

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

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Lack of falls assessment and care planning

Concerns raised2

Failure to complete Multifactorial Risk Assessments at admission and after hospital transfers or falls

Failure to complete regular ward audits of falls risk assessments

Concerns raised4

Unavailability of an appointed Falls Lead

Failure to complete the Falls Risk Assessment

Failure of the Falls Policy to comply with NICE Guidelines

Failure to complete the Falls Policy

Concerns raised2

Lack of documentation demonstrating post-fall review of residents’ risk assessments

Delays in completing post-fall risk assessment reviews

Linked response

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

Concerns raised1

Failure to complete falls risk assessments

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to implement falls risk measures consistently and effectively

Linked response

Stated actions 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

Concerns raised2

Failure to maintain observational charts for patients at risk of falls

Failure to document daily and post-change falls-risk reassessments

Linked response

Stated actions 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.1

Stated actions 1

Stated actions 3

Stated actions 2

Respondent positions 2

Stated actions 2

Respondent positions 1