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.

29 Nov2016
County Durham and Darlington
Concerns raised1
1. Lack of risk assessment for falls and pressure sore risk
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 1
1. Action
  Phase in air-flow mattresses through Home Loans for residents with an assessed need for pressure-relief care.
  Stated by Lambton HouseStated in progress
AI-generated summary

Name not published · 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

The deceased, who had a history of falls and was assessed as being at risk of falling, was found on the floor after an unwitnessed night and sustained injuries that subsequently led to her death. Concerns included the absence of adequate risk assessments for falls and pressure sores, and the failure to identify that a new mattress was unsuitable for her.

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 risk assessment for falls and pressure sore risk
Wider context from the report
“(1) It became apparent that a risk assessment was not completed in relation to the deceased's falls and the pressure sore risk. The deceased was found on the floor after an unwitnessed night by a carer at approximately 4.00 hours. She sustained injuries which subsequently led to her death. ”
Source location
Name not published · 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
Phase in air-flow mattresses through Home Loans for residents with an assessed need for pressure-relief care.

Verbatim wording from the response
“Steps are being taken to further minimise the risk that resident's face in situations such as this. Lambton House is currently in the process of phasing in through “Home Loans” the provision of air flow mattresses, where there has been an assessed need to aid pressure relief care. All new air flow mattresses are compatible with bed based pressure sensors. The aim is to eliminate the need for floor based pressure sensors, which in themselves can also create a risk of falls/trips.”

Source location
2016-0423-Response-by-Lambton-House-Care-Home
Page 1 · response
Published 26 February 2017
Open published response
24 Nov2016
Black Country
Concerns raised2
1. Lack of completed falls risk assessments
2. Failure to justify moving patients at risk of falls from monitored to unmonitored bays
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.

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

Mrs Beryl Farmer · 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 Farmer was admitted to hospital with severe hypocalcaemia and postural hypotension, fell from her bed and sustained facial and head injuries, and was discharged without a documented falls risk assessment. She was readmitted after developing headaches, was diagnosed with a subdural haemorrhage, later developed seizures, and died; concerns included inadequate falls-risk assessment, moving her to an unmonitored bay, limited neurological observations, and no CT head scan after the 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
Lack of completed falls risk assessments
Wider context from the report
“1. Evidence emerged during the inquest that Mrs Farmer had a risk of a falling (moderate to high risk). There was no evidence that a falls risk assessment had been completed. ”
Source location
Mrs Beryl Farmer · 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 justify moving patients at risk of falls from monitored to unmonitored bays
Wider context from the report
“2. Given the risks of falls, there was no clear justification for moving her from a monitored bay to an unmonitored bay. ”
Source location
Mrs Beryl Farmer · Prevention of Future Deaths report
Page 2 · concerns
Open source report
7 Nov2016
South Wales Central
Concerns raised1
1. Failure to provide indicated continuous 1:1 supervision for a high falls-risk patient
This report raised 5 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 5
1. Action
  Commence and regularly review falls care plans for all patients identified as at risk.
  Stated by Cardiff & Vale University LHBStated completed
2. Action
  Discuss falls risk assessment outcomes and 1:1 specialling requirements with families and carers, incorporating their views.
  Stated by Cardiff & Vale University LHBStated completed
3. Action
  Restrict staff assigned to specialling to duties that do not take them away from providing specialling.
  Stated by Cardiff & Vale University LHBStated completed
1. Action
  Benchmark enhanced observational care against other organisations across Wales and England.
  Stated by Cardiff & Vale University LHBStated in progress
2. Action
  Carry out the Specialling of Patients project in Medicine Clinical Board wards.
  Stated by Cardiff & Vale University LHBStated in progress
AI-generated summary

Maurice ISAACS · 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

Maurice ISAACS, who had dementia and other chronic health conditions, was admitted to hospital after deteriorating and suffered multiple falls. He fell from his bed on 12 June 2016, sustained a head injury and died two days later. Concerns included shortcomings in falls-risk assessment, care planning and supervision, as well as failures in carrying out and overseeing neurological observations after the final 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 provide indicated continuous 1:1 supervision for a high falls-risk patient
Wider context from the report
“(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded. For example, no clear care plan was introduced until after the fourth fall. Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation. Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis. Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward. His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated. The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that, might have prevented so many falls. ”
Source location
Maurice ISAACS · 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
Commence and regularly review falls care plans for all patients identified as at risk.

Verbatim wording from the response
“The Medicine Clinical Board, in conjunction with all Directorates, have put in place the following key changes to identify how risk is assessed and the level of specialling that a patient requires to support a more holistic approach. When completing the falls risk assessment, all patients identified as at risk have a falls care plan commenced. This care plan is reviewed weekly, or more frequently as the patient’s health and requirements change. Since the tragic incident involving Mr I, the Clinical Board recognises the need for more robust discussion of the risk assessment outcome and the need for 1:1 specialling with families/carers. Families and carers are now actively encouraged to share their opinions if they feel 1:1 specialling is not appropriate for their relative or if they may respond poorly to this type of enhanced monitoring.”

Source location
2016-0411-Response-by-Uiniversity-Hospital-of-Wales
Page 2 · response
Published 9 February 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Discuss falls risk assessment outcomes and 1:1 specialling requirements with families and carers, incorporating their views.

Verbatim wording from the response
“The Medicine Clinical Board, in conjunction with all Directorates, have put in place the following key changes to identify how risk is assessed and the level of specialling that a patient requires to support a more holistic approach. When completing the falls risk assessment, all patients identified as at risk have a falls care plan commenced. This care plan is reviewed weekly, or more frequently as the patient’s health and requirements change. Since the tragic incident involving Mr I, the Clinical Board recognises the need for more robust discussion of the risk assessment outcome and the need for 1:1 specialling with families/carers. Families and carers are now actively encouraged to share their opinions if they feel 1:1 specialling is not appropriate for their relative or if they may respond poorly to this type of enhanced monitoring.”

Source location
2016-0411-Response-by-Uiniversity-Hospital-of-Wales
Page 2 · response
Published 9 February 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Restrict staff assigned to specialling to duties that do not take them away from providing specialling.

Verbatim wording from the response
“Nursing staff that have been identified to provide specialling have been informed that they are not to participate in care that would take them away from their role of providing specialling. The Clinical Board are currently undertaking benchmarking of enhanced observational care within other organisations across Wales and England.”

Source location
2016-0411-Response-by-Uiniversity-Hospital-of-Wales
Page 3 · response
Published 9 February 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Benchmark enhanced observational care against other organisations across Wales and England.

Verbatim wording from the response
“Nursing staff that have been identified to provide specialling have been informed that they are not to participate in care that would take them away from their role of providing specialling. The Clinical Board are currently undertaking benchmarking of enhanced observational care within other organisations across Wales and England.”

Source location
2016-0411-Response-by-Uiniversity-Hospital-of-Wales
Page 3 · response
Published 9 February 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Carry out the Specialling of Patients project in Medicine Clinical Board wards.

Verbatim wording from the response
“The UHB is currently carrying out a project on the ‘Specialling of patients’ which we hope to have in place in the Medicine Clinical Board ward areas in February 2017.”

Source location
2016-0411-Response-by-Uiniversity-Hospital-of-Wales
Page 3 · response
Published 9 February 2017
Open published response
26 Aug2016
Manchester South
Concerns raised1
1. Failure to complete required falls risk assessments
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
  Share the Coroner’s Inquest findings with Ward E2 staff and highlight the need to review falls risk assessments when bed-bound patients begin sitting out.
  Stated by Stockport NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  The falls risk assessment was completed within six hours of Ward E2 arrival, contrary to the concern that it had not been completed.
  Stated by Stockport NHS Foundation TrustDisputes the concern
AI-generated summary

Maureen Patricia FLYNN · 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

Maureen Patricia FLYNN was admitted to hospital with a urinary tract infection and later suffered a fall from her bedside chair, fracturing her left hip. She underwent surgery, subsequently developed a chest infection that did not respond to antibiotics, and died on 7 May 2016. Concerns included the incomplete falls risk assessment, staff not being alerted to this, and the Patient Safety Investigation not identifying the omission.

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 required falls risk assessments
Wider context from the report
“The evidence at the Inquest suggested that if, from the falls risk assessment, there were concerns as to Mrs Flynn’s mobilising in and out bed and/or in and out of her chair and her stability then these would have been highlighted in the nursing notes/care plan and discussed at any handover. However, as the assessment had not been completed out no-one knew, least of all the HCA. It is of concern to me that those caring for a patient were ignorant of the fact that Mrs Flynn’s falls risk assessment had not been completed. It is clear that the HCA was unaware. It is reasonable for staff, in my view, to assume that all assessments have been appropriately carried out and completed. Why would the HCA have thought otherwise given the high falls risk sign above Mrs Flynn’s bed? It would seem eminently sensible to adopt a system whereby staff are alerted to the fact that a falls risk assessment has not been completed. My concern extends to any other assessment required for a patient’s safety and well-being. I am further concerned that the Patient Safety Investigation did not identify the fact that the falls risk assessment had not been completed. ”
Source location
Maureen Patricia FLYNN · 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
Share the Coroner’s Inquest findings with Ward E2 staff and highlight the need to review falls risk assessments when bed-bound patients begin sitting out.

Verbatim wording from the response
“Following the investigation, Ward E2 shared the findings of the investigation via their Newsletter in June 2016. Please see attached the June ward newsletter for your information (page 2). In August 2016, I can confirm that the findings of the Coroner's Inquest was shared on Ward E2 and attention drawn to the need for fall risk assessments to be reviewed when a bed-bound patient starts to sit out in a chair. Please see attached the August ward newsletter for your information (page 2).”

Source location
2016-0310-Response-by-Stockport-NHS-Trust
Page 3 · response
Published 26 August 2016
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 falls risk assessment was completed within six hours of Ward E2 arrival, contrary to the concern that it had not been completed.

Verbatim wording from the response
“As confirmed above, the falls risk assessment had been completed within 6 hours of the patient's arrival to Ward E2 and this was in line with Trust policy. This assessment deemed the patient to be at risk of falls and bed rails were in situ. As the falls risk assessment was completed appropriately, this was not deemed to be a care or service delivery problem and therefore was not included within the Patient Safety Investigation report.”

Source location
2016-0310-Response-by-Stockport-NHS-Trust
Page 3 · response
Published 26 August 2016
Open published response
26 Jul2016
Inner North London
Concerns raised4
1. Failure to complete nursing sections of post-falls checklists
2. Failure to conduct required neurological observations after falls
3. Failure to draft falls prevention care plans after identified increased falls risk
1. Inaccurate recording of walking aids in falls risk assessments
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 2
1. Action
  Deliver multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.
  Stated by Barts Health NHS TrustStated completed
2. Action
  Implement falls-risk identification and prevention measures, including standardised assessment, high-risk wristbands, direct-observation bays and monthly falls-reduction monitoring.
  Stated by Barts Health NHS TrustStated completed
AI-generated summary

Margaret Emily TUCK · 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

Margaret Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

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 nursing sections of post-falls checklists
Wider context from the report
“3. After her fall, Mrs Tuck was seen by a junior doctor who examined her thoroughly and filled in the medical portion of the post falls checklist. However, the nursing aspect of this form was never completed. The FY1 had wanted a neurological observation to be undertaken in addition to the protocol neurological observations of every 30 minutes, but her note was not wholly clear, and could have been interpreted as seeking only one neurological observation in total. In fact, no neurological observations at all were conducted on the day that Mrs Tuck fell, nor the day after. The FY1 doctor had wanted to speak to the primary nurse before leaving the bedside, but had been unable to find her. The twin nursing failures of documentation and observation might have been avoided if such a conversation had been mandatory, and there had been a simple way of achieving this. ”
Source location
Margaret Emily TUCK · 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 conduct required neurological observations after falls
Wider context from the report
“3. After her fall, Mrs Tuck was seen by a junior doctor who examined her thoroughly and filled in the medical portion of the post falls checklist. However, the nursing aspect of this form was never completed. The FY1 had wanted a neurological observation to be undertaken in addition to the protocol neurological observations of every 30 minutes, but her note was not wholly clear, and could have been interpreted as seeking only one neurological observation in total. In fact, no neurological observations at all were conducted on the day that Mrs Tuck fell, nor the day after. The FY1 doctor had wanted to speak to the primary nurse before leaving the bedside, but had been unable to find her. The twin nursing failures of documentation and observation might have been avoided if such a conversation had been mandatory, and there had been a simple way of achieving this. ”
Source location
Margaret Emily TUCK · 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 draft falls prevention care plans after identified increased falls risk
Wider context from the report
“1. Although a falls risk assessment was conducted upon Margaret Tuck’s admission to hospital, when it demonstrated an increased risk of falling no falls prevention care plan was drafted. And, whilst most of the preventative measures that would have been detailed on such a care plan were implemented in any event, Mrs Tuck was described on the risk assessment as having no walking aids. In fact, she had a Zimmer frame, and it was while reaching for this Zimmer frame that she fell on the acute admissions unit. ”
Source location
Margaret Emily TUCK · 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
Inaccurate recording of walking aids in falls risk assessments
Wider context from the report
“1. Although a falls risk assessment was conducted upon Margaret Tuck’s admission to hospital, when it demonstrated an increased risk of falling no falls prevention care plan was drafted. And, whilst most of the preventative measures that would have been detailed on such a care plan were implemented in any event, Mrs Tuck was described on the risk assessment as having no walking aids. In fact, she had a Zimmer frame, and it was while reaching for this Zimmer frame that she fell on the acute admissions unit. ”
Source location
Margaret Emily TUCK · 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 multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.

Verbatim wording from the response
“3. Our Nurse Educator has been instrumental in setting up and delivering a new multi-disciplinary training programme around important issues, that includes falls prevention awareness and post falls care. As part of the Band 7 role regular assessment during the shift of care planned and delivered, is undertaken. All of our medical staff, including FY1’s, are invited to participate. Falls prevention and awareness is also included in the FY1 mandatory education programme. With the increased presence of Band 6 and 7 nurses on each shift all the clinical staff now have a first contact who they can handover important issues to, even when the named nurse is not on the ward. There are now four multidisciplinary board / handover meetings per 24-hours and these are focussed around patient safety and handover.”

Source location
2016-0273-Response-by-Barths-Health-NHS-Trust
Page 3 · response
Published 26 July 2016
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
Implement falls-risk identification and prevention measures, including standardised assessment, high-risk wristbands, direct-observation bays and monthly falls-reduction monitoring.

Verbatim wording from the response
“1. The Hospital has undertaken a major piece of work to ensure vulnerable patients are identified and cared for, ensuring their risk of falling is minimised. A falls working group meets monthly, with each clinical area having to present their incidence of falls and work in progress around reduction of these incidents. On the AAU (representative of most clinical areas) all patients are assessed using the Trust falls assessment paperwork (which has been newly amalgamated into a nursing documentation admissions booklet), and any patient identified as a high risk, is then issued with a brightly coloured wrist band with the words ‘HIGH RISK OF FALLS’ printed on it. This signals to all staff, whether regular or agency, that this patient is at risk. All our high risk patients are now under within a bay that allows direct observation by nurses at the nurses’ station.”

Source location
2016-0273-Response-by-Barths-Health-NHS-Trust
Page 3 · response
Published 26 July 2016
Open published response
10 May2016
Brighton and Hove
Concerns raised1
1. Failure to complete admission and fall documentation
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 4
1. Action
  Follow up poor documentation with nursing and medical staff.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Remind staff through weekly communications to follow observation policy, use the one-to-one care pathway and document care comprehensively and contemporaneously.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
3. Action
  Organise a monthly neurosurgical records audit to improve documentation quality.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
1. Action
  Conduct senior-nurse records spot checks, remedy shortcomings and educate staff on improving records.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
AI-generated summary

Christine Valerie STREET · 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

Christine Valerie STREET was admitted to hospital with an aggressive brain tumour causing disorientation, confusion, left-sided weakness and a risk of falling. On 11 September 2015, she was found unattended on a toilet floor after an unwitnessed fall, sustaining a minor head injury that accelerated her deterioration and the timing of her death. The report raised concerns about incomplete documentation, failures to follow observation procedures, the use and training of bank staff, and flawed recognition and management of the dying patient.

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 admission and fall documentation
Wider context from the report
“(1) Documentation with regard to the admission document (which was not completed) and the doctors pro forma to document the fall on the 11th September 2015 (was not completed). The lack of these documents did not affect the outcome, but it is bad practice that they were not completed and placed with Mrs. Street’s notes. ”
Source location
Christine Valerie STREET · 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
Follow up poor documentation with nursing and medical staff.

Verbatim wording from the response
“I am aware that the quality of documentation for Mrs Street was poor in several respects and this has been followed up with both nursing and medical staff. The staff had recognised that Mrs Street was at high risk of falls, and had intended her to have constant attention knowing that she lacked capacity to comprehend her risk of falling as a result of the tumour. It appears that the ward nurses had mistakenly thought that the ‘care record for patient requiring specialising’, which was available as an appendix to the Trust’s ‘policy for the observation of adult patients with mental health problems’, was not intended for use when caring for a patient who was suffering not from a mental illness but from a specific neurological condition - in this instance, a brain tumour. Rapid action was taken when this came to light, to correct their understanding.”

Source location
2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 10 May 2016
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
Remind staff through weekly communications to follow observation policy, use the one-to-one care pathway and document care comprehensively and contemporaneously.

Verbatim wording from the response
“It is particularly disappointing that Mrs Street was injured in a fall as this Trust has worked very hard indeed over several years to implement an active falls prevention programme. As a result the Trust has one of the lowest rates of inpatient falls of any acute Trust in the country. Nevertheless, in her weekly message to staff, the Chief Executive has”

Source location
2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 10 May 2016
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
Organise a monthly neurosurgical records audit to improve documentation quality.

Verbatim wording from the response
“In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records.”

Source location
2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 10 May 2016
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
Conduct senior-nurse records spot checks, remedy shortcomings and educate staff on improving records.

Verbatim wording from the response
“In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records.”

Source location
2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 10 May 2016
Open published response
10 Dec2015
Nottinghamshire
Concerns raised6
1. Failure to report falls
2. Failure to record falls
3. Failure to hand over falls
1. Lack of falls risk assessments
2. Lack of clarity about staff responsibilities for handing over, recording and reporting falls
3. Failure to refer residents to the Falls Team
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Introduce a staff handover document recording daily responsibilities and identifying the senior person in charge.
  Stated by Your Health LimitedStated completed
2. Action
  Alter shift patterns to create overlap for a protected, paid handover.
  Stated by Your Health LimitedStated completed
3. Action
  Use a multifactorial falls risk assessment covering nighttime risks.
  Stated by Your Health LimitedStated completed
1. Action
  Use a falls management folder containing assessment tools, including a bed-rail risk assessment and algorithm.
  Stated by Your Health LimitedStated completed
AI-generated summary

Elsie Marjorie Brown · 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

Elsie Marjorie Brown fell from her bed at Langwith Lodge Residential Care Home on 23 March 2015, suffering fractures to her left humerus and right hip. She died in hospital on 5 April 2015 from bronchopneumonia and lobar pneumonia, which developed as a result of the fractures. Concerns included the absence of falls-risk and bed-rails assessments, an incomplete and unreviewed care plan, unclear responsibilities, inadequate recording and handovers, insufficient auditing, and potentially inadequate night staffing.

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
“6. Mrs Brown’s fall on 23rd March 2013 was not handed over, nor recorded nor reported, and there was a lack of clarity amongst staff as to where responsibilities for these matters rested. ”
Source location
Elsie Marjorie Brown · 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 record falls
Wider context from the report
“6. Mrs Brown’s fall on 23rd March 2013 was not handed over, nor recorded nor reported, and there was a lack of clarity amongst staff as to where responsibilities for these matters rested. ”
Source location
Elsie Marjorie Brown · 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 hand over falls
Wider context from the report
“6. Mrs Brown’s fall on 23rd March 2013 was not handed over, nor recorded nor reported, and there was a lack of clarity amongst staff as to where responsibilities for these matters rested. ”
Source location
Elsie Marjorie Brown · 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
Lack of falls risk assessments
Wider context from the report
“1. There was no falls risk assessment nor bed rails assessment in place for Mrs Brown, nor was her mental capacity assessed. ”
Source location
Elsie Marjorie Brown · 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
Lack of clarity about staff responsibilities for handing over, recording and reporting falls
Wider context from the report
“6. Mrs Brown’s fall on 23rd March 2013 was not handed over, nor recorded nor reported, and there was a lack of clarity amongst staff as to where responsibilities for these matters rested. ”
Source location
Elsie Marjorie Brown · 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 refer residents to the Falls Team
Wider context from the report
“3. No referral was made to the Falls Team nor (by Langwith Lodge) to Derbyshire Community Health as regards the question of bed rails. ”
Source location
Elsie Marjorie Brown · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce a staff handover document recording daily responsibilities and identifying the senior person in charge.

Verbatim wording from the response
“The Company has noted that there was some confusion as to who had overall responsibility when 2 senior staff were on duty and we introduced a staff handover document in September 2015 (attached) to document the daily responsibilities of individual staff on duty, as well as clearly outlining who the senior staff on duty were, and who was ultimately in charge of running the home.”

Source location
Elsie-Brown-Response
Page 3 · response
Published 4 December 2015
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
Alter shift patterns to create overlap for a protected, paid handover.

Verbatim wording from the response
“The Company has always recognised the importance of handovers as part of the daily routine for operating a service that runs 24 hours a day, 365 days a year. We are keen to ensure that the handover is a protected part of the day and is not interrupted in any way. We have consulted with staff and altered their shift patterns with effect from 21st January 2015, to ensure that we have an overlap of shifts which allows for a paid handover to take place to relay information about the people we are provided care and support to. We feel this will formalise the current system and make our handover process more robust.”

Source location
Elsie-Brown-Response
Page 4 · response
Published 4 December 2015
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
Use a multifactorial falls risk assessment covering nighttime risks.

Verbatim wording from the response
“The Company did have corporate documentation in relation to falls risk assessment at the time of the incident. The ‘Multi-factorial falls risk assessment’ (attached) was introduced in 2014. This documentation allows Senior and Managerial staff to assess the likelihood of a resident suffering a fall and includes a section about the risks at night time.”

Source location
Elsie-Brown-Response
Page 1 · response
Published 4 December 2015
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
Use a falls management folder containing assessment tools, including a bed-rail risk assessment and algorithm.

Verbatim wording from the response
“A falls management folder was introduced at Langwith in April 2015, which contains a number of different assessment tools to assist staff in reviewing the safety of a resident who is at risk of falls. This includes a specific bed rail risk assessment and algorithm (attached).”

Source location
Elsie-Brown-Response
Page 2 · response
Published 4 December 2015
Open published response
11 Nov2015
Inner North London
Concerns raised1
1. Lack of supervision arrangements for falls and mobilisation risk
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 5
1. Action
  Include verbal handover of falls-risk patients’ care plans in nursing handover safety briefings.
  Stated by Barts Health NHS TrustStated completed
2. Action
  Review escalation of one-to-one supervision requests and enable out-of-hours site-manager contact for patients at risk of falls or confusion.
  Stated by Barts Health NHS TrustStated completed
3. Action
  Move Ward 9F multidisciplinary meetings earlier to develop falls-risk action plans and communicate overnight deterioration.
  Stated by Barts Health NHS TrustStated completed
1. Action
  Recruit a practice development team to support ward adherence to documentation, risk-assessment and communication protocols.
  Stated by Barts Health NHS TrustStated completed
2. Action
  Provide Falls Lead training to retrain nurses in fall procedures and management.
  Stated by Barts Health NHS TrustStated completed
AI-generated summary

David Alan White · Prevention of Future Deaths report

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

Report summary

David Alan White was admitted to hospital with significant pain from arterial vascular disease and later sustained two unwitnessed falls, the second causing fractures to his right hip and shoulder. He underwent emergency surgery and subsequently remained seriously unwell before dying on 26 June 2015. Concerns included the failure to record or act on reported confusion associated with Heparin, lack of supervision despite identified falls risks, and inadequate review and action on nursing records.

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 supervision arrangements for falls and mobilisation risk
Wider context from the report
“(2) Nursing notes documented a risk of falls/mobilisation and action to be taken, but there was no supervision arrangement in place. One to one care had been in contemplation. ”
Source location
David Alan White · 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
Include verbal handover of falls-risk patients’ care plans in nursing handover safety briefings.

Verbatim wording from the response
“2. The safety briefing during nursing handover is now to include a verbal handover of the care plans for patients assessed as at risk of falls to alert incoming staff members as to the risk and care plan.”

Source location
2015-0437-Response
Page 2 · response
Published 11 November 2015
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
Review escalation of one-to-one supervision requests and enable out-of-hours site-manager contact for patients at risk of falls or confusion.

Verbatim wording from the response
“We have reviewed the escalation of our ‘Specials’ requests to Bank Partners so that patients can be appropriately monitored and supervised (one to one) when they are assessed as at risk of falls and/or confused. Site managers can now be contacted out of hours to ensure appropriate management of care.”

Source location
2015-0437-Response
Page 2 · response
Published 11 November 2015
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
Move Ward 9F multidisciplinary meetings earlier to develop falls-risk action plans and communicate overnight deterioration.

Verbatim wording from the response
“3. Multidisciplinary Team meetings on Ward 9F have now been changed to earlier in the day to discuss patients and make effective action plans for patient at risk of falls. This meeting consists of medical/surgical teams, physiotherapy, Occupational Therapists and the Ward Nurse in charge and includes a medical handover to ensure communication of any deterioration overnight that could influence risk of falls, such as increased confusion.”

Source location
2015-0437-Response
Page 2 · response
Published 11 November 2015
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
Recruit a practice development team to support ward adherence to documentation, risk-assessment and communication protocols.

Verbatim wording from the response
“A practice development team has been recruited to support ward staff in adhering to ward protocols and procedures including documentation, assessment of risks and communication. We also have facilitated training from the ‘Falls Lead’ for the Trust to re-train nurses regarding the fall procedure and management and this took place on 29 June 2015.”

Source location
2015-0437-Response
Page 2 · response
Published 11 November 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide Falls Lead training to retrain nurses in fall procedures and management.

Verbatim wording from the response
“A practice development team has been recruited to support ward staff in adhering to ward protocols and procedures including documentation, assessment of risks and communication. We also have facilitated training from the ‘Falls Lead’ for the Trust to re-train nurses regarding the fall procedure and management and this took place on 29 June 2015.”

Source location
2015-0437-Response
Page 2 · response
Published 11 November 2015
Open published response
26 Oct2015
Birmingham and Solihull
Concerns raised5
1. Lack of staff awareness of the Falls Prevention Policy
2. Failure to escalate falls to appropriate senior staff
3. Failure to complete the falls tracker
1. Failure to complete the falls monthly log daily
2. Failure to correctly record falls
This report raised 5 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

Allan Richard Beasley · 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

Allan Richard Beasley, who had vascular dementia, was admitted to a care home after he could no longer manage at home and experienced multiple falls. Following a further fall, he was diagnosed with cervical spine fractures, developed a chest infection, deteriorated and died. Concerns included inadequate falls-risk assessment, failures to record and escalate falls, inaccurate observation records, and incomplete monitoring and 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 staff awareness of the Falls Prevention Policy
Wider context from the report
“(1) Staff were unaware of the Home’s Falls Prevention Policy. This meant staff failed to correctly record falls and escalate to appropriate senior staff. ”
Source location
Allan Richard Beasley · 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 escalate falls to appropriate senior staff
Wider context from the report
“(1) Staff were unaware of the Home’s Falls Prevention Policy. This meant staff failed to correctly record falls and escalate to appropriate senior staff. ”
Source location
Allan Richard Beasley · 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 the falls tracker
Wider context from the report
“(7) The falls tracker was not completed for Mr Beasley. ”
Source location
Allan Richard Beasley · 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 the falls monthly log daily
Wider context from the report
“(2) The falls monthly log was not completed on a daily basis as it should have been. The log was not completed for June as staff were too busy. This resulted in trends being missed and staff being unaware of the frequency of Mr Beasley’s falls. ”
Source location
Allan Richard Beasley · 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 correctly record falls
Wider context from the report
“(1) Staff were unaware of the Home’s Falls Prevention Policy. This meant staff failed to correctly record falls and escalate to appropriate senior staff. ”
Source location
Allan Richard Beasley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
3 Sep2015
Manchester South
Concerns raised2
1. Lack of staff awareness of the policy for reporting falls
2. Failure to obtain staff confirmation of receipt of fall-response training
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

May Hall · 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

May Hall fell twice during the night of 11/12 April 2015, banging her head on both occasions, and later died from a subdural haematoma. Staff at Bourne House indicated that they were not aware of a policy for reporting falls or calling an ambulance or emergency doctor, and the report identified a need for clear, regularly reviewed staff training on responding to 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
Lack of staff awareness of the policy for reporting falls
Wider context from the report
“The Bourne House staff indicated that they were not aware of a policy for reporting falls and for calling the ambulance or emergency doctor. There should be clear training as to how any fall should be addressed by the staff and they should sign to confirm that they have received such training which should be regularly reviewed. ”
Source location
May Hall · 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 obtain staff confirmation of receipt of fall-response training
Wider context from the report
“The Bourne House staff indicated that they were not aware of a policy for reporting falls and for calling the ambulance or emergency doctor. There should be clear training as to how any fall should be addressed by the staff and they should sign to confirm that they have received such training which should be regularly reviewed. ”
Source location
May Hall · 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

Lack of risk assessment for falls and pressure sore risk

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 raised2

Lack of completed falls risk assessments

Failure to justify moving patients at risk of falls from monitored to unmonitored bays

Concerns raised1

Failure to provide indicated continuous 1:1 supervision for a high falls-risk patient

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Failure to complete required falls risk assessments

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

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

Concerns raised4

Failure to complete nursing sections of post-falls checklists

Failure to conduct required neurological observations after falls

Failure to draft falls prevention care plans after identified increased falls risk

Inaccurate recording of walking aids in falls risk assessments

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

Concerns raised1

Failure to complete admission and fall documentation

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised6

Failure to report falls

Failure to record falls

Failure to hand over falls

Lack of falls risk assessments

Lack of clarity about staff responsibilities for handing over, recording and reporting falls

Failure to refer residents to the Falls Team

Actions described in response 1

Actions described in response 5

Actions described in response 1

Respondent positions 1

Actions described in response 2

Actions described in response 4