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.

3 Sep2018
Manchester South
Concerns raised1
1. Failure to investigate repeated falls
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

Mrs Doris Douthwaite · 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

Mrs Doris Douthwaite, who had vascular dementia and other complex medical conditions, suffered three falls at Greatwood House Residential Care Home over 11–13 February 2018. She sustained a hip fracture, developed bronchopneumonia and died at Willow Wood Hospice on 26 February 2018. Concerns included vulnerable residents being left unsupervised, an unclear falls assessment tool, and the absence of an investigation into Mrs Douthwaite’s falls.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to investigate repeated falls
Wider context from the report
“3. Notwithstanding the fact Mrs Douthwaite had 3 falls over the course of as many days in February 2018, HC-One had not, as at the date of the Inquest, undertaken any investigation into the circumstances of these. The absence of any investigation by HC-One in this respect represents a missed opportunity to ascertain if any learning can be derived from these incidents for the benefit of other residents. ”
Source location
Mrs Doris Douthwaite · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Jul2018
Coventry
Concerns raised1
1. Insufficient staffing to provide required supervision for residents at risk of 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.

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

Ruth Marian Perkin · 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

Ruth Marian Perkin was admitted to a care home on 9 February 2018, suffered two falls shortly afterwards, and was found to have a right neck of femur fracture after the second fall. She underwent hip repair, later contracted pneumonia, and died on 29 March 2018. The principal concern was that discharge to the care home while her needs were still being assessed, together with staffing and care arrangements, may have increased her risk of falls and death.

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
Insufficient staffing to provide required supervision for residents at risk of falls
Wider context from the report
“(4) I was informed by the Care Home Manager that if Mrs Perkin not suffered a fracture and had been returned to the care of the Care Home after her second fall, she would have suggested to the hospital that, in view of Mrs Perkin’s tendency to act in disregard of care instructions, she was in fact most likely in need of 1:1 care. (5) I was informed that for the 20 residents at the Care Home there are 5 staff on duty during the day, reducing to 3 staff at night, and my concern is that Mrs Perkin’s discharge to the Care Home under the D2A scheme, when her needs were still being assessed, actually placed her at an increased risk of falls and death as a result. ”
Source location
Ruth Marian Perkin · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Jul2018
South London
Concerns raised1
1. Unavailability of sensor systems for alerting staff to resident 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.

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

Doris McCarthy · 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

Doris McCarthy, a resident of Baycroft Orpington, had recurrent falls and was involved in two incidents where she slid from a chair without the sensor system alerting staff. The principal concerns were continuing sensor system outages and the steps taken to safeguard residents known to slide when seated in chairs; the inquest concluded that she died from natural causes resulting from a pulmonary embolism, with an underlying subdural haemorrhage caused by recurrent falls.

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 sensor systems for alerting staff to resident falls
Wider context from the report
“(1) The sensor system outages might still exist, leaving residents vulnerable due to staff not being alerted to a fall ”
Source location
Doris McCarthy · Prevention of Future Deaths report
Page 1 · concerns
Open source report
14 May2018
Northamptonshire
Concerns raised6
1. Lack of a mechanism to ensure safe delivery and discharge of Falls Prevention Service input
2. Failure to transmit and resubmit completed falls action plans through the required process
3. Failure to use appropriate falls referral thresholds
1. Unavailability of required falls prevention equipment
2. Failure to consider and action falls risk action plan advice
3. Failure to make new falls prevention referrals after further 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 1
1. Action
  Contact the Falls Team after sending referrals and action plans, confirm receipt and intended action, and record each contact in residents’ care plans.
  Stated by Avenue House Nursing and Care HomeStated planned
Respondent positions 3
1. Position
  After submitting referrals and action plans, the care home must wait for the Falls Team’s input and decisions.
  Stated by Avenue House Nursing and Care HomeRedirects responsibility
1. Position
  The company’s policy requiring referral after three known falls is considered reasonable and sufficient.
  Stated by Avenue House Nursing and Care HomeExisting arrangements considered sufficient
2. Position
  Floor-based sensor mats and staff monitoring are considered sufficient; bed sensors offer no additional advantage and communal-area sensors are unsafe.
  Stated by Avenue House Nursing and Care HomeExisting arrangements considered sufficient
AI-generated summary

Gladys Kathleen Rich · 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

Gladys Kathleen Rich suffered repeated falls after moving into Avenue House Nursing and Care Home, culminating in a fall on 28 December 2016 that caused traumatic subdural and subarachnoid haemorrhages and a skull fracture. She died on 3 March 2017; the medical cause of death included chest infection, intracranial haemorrhage and a fall, with rectal cancer and liver metastases also recorded. The principal concerns related to failures to identify and manage her falls risk, ineffective referral and follow-up by the care home and Falls Prevention Service, inadequate resources and equipment, and the absence of an effective system to ensure required falls-prevention input was delivered.

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 a mechanism to ensure safe delivery and discharge of Falls Prevention Service input
Wider context from the report
“3. There does not seem to be any mechanism for ensuring that Falls Prevention Service input is in fact delivered when it is required and that a patient is only ever discharged or that it is clear that the underlying symptoms causing the falls are resolved or that measures have been put in place to mitigate the falls risk. ”
Source location
Gladys Kathleen Rich · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to transmit and resubmit completed falls action plans through the required process
Wider context from the report
“c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service. ”
Source location
Gladys Kathleen Rich · Prevention of Future Deaths report
Page 3 · 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 appropriate falls referral thresholds
Wider context from the report
“b) The policy of waiting for 3 falls before making a referral seems to be arbitrary and also at odds with the Fall Prevention Service requirement of 1 fall within a 12 month period before a referral will be accepted. ”
Source location
Gladys Kathleen Rich · Prevention of Future Deaths report
Page 3 · 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
Unavailability of required falls prevention equipment
Wider context from the report
“d) The care home may not have some of the equipment that they require for patients such as Mrs Rich e.g. a bed sensor mat. ”
Source location
Gladys Kathleen Rich · Prevention of Future Deaths report
Page 3 · 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 consider and action falls risk action plan advice
Wider context from the report
“c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service. ”
Source location
Gladys Kathleen Rich · Prevention of Future Deaths report
Page 3 · 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 new falls prevention referrals after further falls
Wider context from the report
“c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service. ”
Source location
Gladys Kathleen Rich · Prevention of Future Deaths report
Page 3 · 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
Contact the Falls Team after sending referrals and action plans, confirm receipt and intended action, and record each contact in residents’ care plans.

Verbatim wording from the response
“Although we believe we followed normal and reasonable procedures in this case, in future to further mitigate against shortcomings of the Falls Team, we will contact them after sending them referrals and action plans. This will be done to ensure that the Falls Team have received them and to find out what action they intend to take. All contact will be recorded in our residents’ Care plans under the visiting professionals’ information section.”

Source location
2018-0149_Redacted-Response-by-Avenue-House-Care-Home
Page 1 · response
Published 8 July 2018
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
After submitting referrals and action plans, the care home must wait for the Falls Team’s input and decisions.

Verbatim wording from the response
“C) The management of the home completed the falls risk assessment and action plan and sent this by post, and not by the fax facility. There was a copy of this in the resident’s file for reference. There was no information in the resident’s file to say that the falls team hadn’t received this information. Mrs Rich had also been referred to the Falls Team prior to admission to Avenue House and again this was not followed up by the Falls Team. Once falls risk action plans are received by the falls team, they do not typically give the home even a rough estimate of how long it will be before it is followed up and the resident is seen. Therefore the care home simply has to wait for the Falls’ Team’s input.”

Source location
2018-0149_Redacted-Response-by-Avenue-House-Care-Home
Page 1 · response
Published 8 July 2018
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 company’s policy requiring referral after three known falls is considered reasonable and sufficient.

Verbatim wording from the response
“B) The management of the home followed the company’s policy about making a referral after three falls (that it was aware of). We believe the company’s policy is reasonable and is common across the care home industry. However, if the home had been informed of Mrs Rich’s previous falls, and her previous referrals to the falls team, the home would have referred Mrs Rich sooner under this reasonable and balanced policy. The Coroner should also note that the home has recently referred residents, who have had 3 or 4 falls to the Falls Team, and even after this number of falls, the Falls Team have made the decision not to get involved in the management of these residents’ falls.”

Source location
2018-0149_Redacted-Response-by-Avenue-House-Care-Home
Page 1 · response
Published 8 July 2018
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
Floor-based sensor mats and staff monitoring are considered sufficient; bed sensors offer no additional advantage and communal-area sensors are unsafe.

Verbatim wording from the response
“out of bed, she did have a sensor mat on the floor by her bed, which did alert staff if she was up and walking around her bedroom. A floor based sensor mat is the normal equipment used in care homes for residents at risk of falls. Bed sensor mats are extremely rare and we believe do not offer any advantages over floor based pressure mats. Mrs Rich also had falls in the communal areas of the home and unfortunately no sensor could safely be used to reduce the likelihood of these. However, staff were aware of her high falls risk, and did monitor her when mobilising independently with her frame.”

Source location
2018-0149_Redacted-Response-by-Avenue-House-Care-Home
Page 2 · response
Published 8 July 2018
Open published response
12 May2018
Derby and Derbyshire
Concerns raised1
1. Failure to undertake basic and proper investigations 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.
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

CHARLES EVAN GRAINGER · 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

Charles Evan Grainger was admitted to Milford House Residential Unit after a fall and later sustained injuries in a witnessed fall there on 24 November 2013. The inquest concluded that his death was accidental, with the medical cause recorded as bronchopneumonia and central cord syndrome. Concerns included failures to share his history of falls between relevant agencies and inadequate investigation of the circumstances surrounding his fall.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to undertake basic and proper investigations of falls risk assessments
Wider context from the report
“(2) ████████ did not consider it important or necessary to request, review or retain copies of Mr Grainger's falls risk assessment as part of her basic investigation enquiries. Failure to undertake a basic and proper investigation could result in future deaths occurring. ”
Source location
CHARLES EVAN GRAINGER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
3 May2018
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. Delays in reporting falls through the incident reporting system
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 1
1. Action
  Disseminate the incident across the General Medicine Department and Medical division and circulate a memo reinforcing accurate, timely Datix reporting.
  Stated by University Hospitals of North Midlands NHS TrustStated completed
AI-generated summary

Kenneth William Horne · 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 William Horne suffered two falls at Royal Stoke University Hospital, including one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter, there was no nurse-to-nurse discharge call, and the Transfer of Care form was not up to date. He fell approximately six hours after admission to Leek Moorlands Hospital, sustaining a serious chest wall injury, and later died from sepsis, bronchopneumonia and chest wall injury.

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
Delays in reporting falls through the incident reporting system
Wider context from the report
“(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter. (2) There was no nurse to nurse discharge call between the hospitals. (3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital. As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December. ”
Source location
Kenneth William Horne · 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 incident across the General Medicine Department and Medical division and circulate a memo reinforcing accurate, timely Datix reporting.

Verbatim wording from the response
“4. This incident was already shared widely across the General Medicine Department and Medical division. A Memo has been circulated divisionally to reiterate the importance of accurate and timely datix reporting.”

Source location
2018-0131-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 1 July 2018
Open published response
12 Apr2018
Sunderland
Concerns raised1
1. Failure to report falls
This report raised 14 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
  Deliver falls identification, reporting and management training, coaching and competency assessment to Hebburn Court staff, completing remaining coverage.
  Stated by Hc-One LimitedStated in progress
AI-generated summary

Patricia Ann Heslop · 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 Ann Heslop, a 75-year-old care home resident with vascular dementia, suffered an unwitnessed fall and fractured her right neck of femur. Following surgery and a period of immobility, she developed acute bronchopneumonia and died on 9 April 2017. The report raised concerns about the unreported fall, changes in mobility and presentation not being recorded or communicated, incomplete care records, delayed treatment, and staff training and information systems.

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 report falls
Wider context from the report
“1. The fall was unwitnessed and went unreported. ”
Source location
Patricia Ann Heslop · 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 identification, reporting and management training, coaching and competency assessment to Hebburn Court staff, completing remaining coverage.

Verbatim wording from the response
“1.6 Following this incident, action has been taken at Hebburn Court to ensure that all staff have the knowledge, skills and tools to identify, record and manage falls to reduce risk and prevent harm. All staff have been reminded of the importance of alerting nursing colleagues and managers to any fall and documenting within the individuals' records. Learning on this has been facilitated by reassignment of the falls prevention module from our award winning online learning platform, Touchstone. In addition staff have received further coaching and assessment of competencies in this area through staff meetings and individual supervision sessions. Training statistics in this area are currently 93.5% of the staff team and plans remain to press for this to increase to 100% by the end of June 2018.”

Source location
2018-0102-Response-by-HC-One
Page 3 · response
Published 17 June 2018
Open published response
19 Mar2018
Sunderland
Concerns raised1
1. Failure to record falls risk consistently with the assessment score
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

Mrs Sheila Sullivan Ross (Sheila) · 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

Mrs Sheila Sullivan Ross died at Sunderland Royal Hospital on 12 November 2017 after an unwitnessed fall at a care home, sustaining bilateral pubic rami fractures and subsequently deteriorating with urinary sepsis. Concerns included an outdated falls risk assessment tool, limitations in the care home buzzer system that could prevent timely assistance, and poor communication with Sheila’s family.

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 record falls risk consistently with the assessment score
Wider context from the report
“(1) The falls risk assessment tool used by the Care Home staff appeared to be outdated, and the subsequent level of falls risk recorded by staff was not in keeping with the score generated by the assessment tool. ”
Source location
Mrs Sheila Sullivan Ross (Sheila) · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Jan2018
Staffordshire South
Concerns raised1
1. Inadequate falls management policy
This report raised 12 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

John Keith Edwards · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

John Keith Edwards, aged 64, was admitted to a care home for respite and subsequently suffered falls, seizures, reduced mobility, pressure sores and a rapid decline before dying in a nursing home on 19 December 2016. Concerns included inadequate care-home policies and care, failures to seek medical assistance and recognise deterioration, poor record-keeping, and inappropriate placement for his complex needs.

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
Inadequate falls management policy
Wider context from the report
“(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate (2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care (3) Care Home staff applied a seizure policy which was not specific to the resident. (4) Care Home staff failed to seek medical assistance following seizures. (5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home. (6) Care records were retrospectively filled in. (7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done. (8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP. (9) Non patient specific dressings were used on pressure sores. (10) A non-patient specific mattress was used on his bed. (11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition. ”
Source location
John Keith Edwards · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Dec2017
Brighton and Hove
Concerns raised1
1. Failure to complete falls risk assessments
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

Sheila ROSS · 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

Sheila ROSS sustained a fatal fall down a flight of stairs at Carlton House Rest Home on 17 September 2017. The report’s principal concern was that no falls risk assessment had been completed despite earlier indicators of vulnerability; the inquest concluded that the death was accidental, to which neglect contributed.

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
“(1) Mrs Ross became a resident at Carlton House Rest Home in October 2014 following having fallen and fractured her hip, yet even at this early stage a falls risk assessment was not completed for her. The years went by and there were no falls but on the 9th December 2016 Mrs Ross had what was described in the GP’s letter as a fall. The Rest Home Manager described it as ‘slip’ - she slipped off the edge of the bed. This is not uncommon but in the absence of any falls over for over two years it’s worrying and should have triggered a falls risk assessment but it didn’t. In July of 2017 Mrs Ross was admitted to hospital very unwell with sepsis due to coli cystitis. On her return to the Rest Home she was less well and more agitated, her sleep which had always been of irregular pattern became worse and she was wandering more. Physically, she apparently didn’t need a stick but her behaviour was such that it was believed she lacked mental capacity – an application was made and she was placed on a Deprivation of Liberty Safe Guarding Order from the 23rd August 2017. The assessments in connection with this highlighted her vulnerability and the fact that she needed 24 hour care and yet there was still no falls risk assessment carried out. By the time she had the fatal fall on the 17th September when she fell down a flight of stairs (which led to a floor on the Rest Home that she had no need to visit) she still had no falls risk assessment. It is, of course, entirely possible for falls to occur even in the best regulated of situations with all paperwork properly in place. However, if a falls risk assessment had been carried out it would have highlighted Mrs Ross’ inability to make any assessment of her own personal safety and there is a possibility that this fall could have been prevented. Since this catastrophic injury there has been significant changes in personnel at the Rest Home and I have no doubt that steps have been initiated to ensure that all residents have the appropriate risk assessments and I also believe that the Inquest itself will be a catalyst to speed this process up. ”
Source location
Sheila ROSS · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to investigate repeated falls

Concerns raised1

Insufficient staffing to provide required supervision for residents at risk of falls

Concerns raised1

Unavailability of sensor systems for alerting staff to resident falls

Concerns raised6

Lack of a mechanism to ensure safe delivery and discharge of Falls Prevention Service input

Failure to transmit and resubmit completed falls action plans through the required process

Failure to use appropriate falls referral thresholds

Unavailability of required falls prevention equipment

Failure to consider and action falls risk action plan advice

Failure to make new falls prevention referrals after further falls

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.3

Concerns raised1

Failure to undertake basic and proper investigations of falls risk assessments

Concerns raised1

Delays in reporting falls through the incident reporting system

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

Concerns raised1

Failure to report falls

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

Concerns raised1

Failure to record falls risk consistently with the assessment score

Concerns raised1

Inadequate falls management policy

Concerns raised1

Failure to complete falls risk assessments

Actions described in response 1

Respondent positions 3

Actions described in response 1

Actions described in response 1