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

Distinct published reports

Individual concerns
285

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
349

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care14
Care Quality Commission9
Barts Health NHS Trust6
Office of the Chief Coroner5
Aneurin Bevan University LHB4
Manchester University NHS Foundation Trust4
Royal London Hospital4
University Hospitals Sussex NHS Foundation Trust4
East Kent Hospitals University NHS Foundation Trust3
Hc-One Limited3
Swansea Bay University Local Health Board3
University Hospitals Birmingham NHS Foundation Trust3
Barchester Healthcare Limited2
Borough Care Ltd2
Cardiff & Vale University LHB2

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.

  1. Liverpool

    AI-generated summary

    Charles Gavin BRADLEY · 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 Gavin Bradley fell unwitnessed in the Assessment Unit at Arrowe Park Hospital on 21 February 2013 and sustained head injuries that proved fatal. The investigation and inquest identified inadequate record-keeping and communications, including failures concerning his transfer and unclear recording of 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

    Inadequate recording of patient falls

    Wider context from the report

    “During the investigation and inquest into Mr Bradley’s death it was found that the record-keeping and communications at Arrowe Park Hospital were inadequate, ineffective making them unsafe. This was evidenced by findings that though Leeds Teaching Hospital had effective records as to the arrangements for the transfer of Mr Bradley to Arrowe Park on the 21st February 2013, when Mr Bradley arrived at Arrowe Park they were not expecting him. This is likely to have caused added worry and stress to his rehabilitation plan. It is further evidenced by the inadequate recording of his fall on the 21st February 2013. From the evidence it was unclear as to whether it was witnessed or not, was it in a bathroom and if so why was there mention of a filing cabinet near he lay? In other cases the matters reported could result in fatalities. Documentation, recordkeeping and communications are core basic skills for all who work in healthcare. Neither the HEALTH aspect nor the CARE aspect of a health care service can be delivered without these basic skills. It would be helpful to see a cross Trust action plan with regard to the improving documentation, record-keeping and communication in the response to this report ”

    Source location

    Charles Gavin BRADLEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Leicester City and South Leicestershire

    AI-generated summary

    Marjorie Evelyne Keogh · 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

    Marjorie Evelyne Keogh, a resident of Scraptoft Court Residential Care Home, fell through a first-floor landing balustrade while transferring to breakfast on 6 March 2010 and died the following day from bilateral pneumonia and multiple injuries. Concerns included the assessment of her suitability for a first-floor room, staffing levels and the absence of a manager, inconsistent risk and manual-handling assessments, and the strength and compliance of staircase furniture.

    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

    Conflicting falls-risk and manual-handling assessments for resident mobilisation

    Wider context from the report

    “(3) It seemed that there was evidence to indicate that there was conflict between the assessment of risk of falls and the assessment of manual handling, as to how serious a risk there was when Mrs Keogh mobilised. Please provide written evidence of how care plans and associated assessments are carried out. ”

    Source location

    Marjorie Evelyne Keogh · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Inner North London

    AI-generated summary

    Agostino COSTA · 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

    Agostino Costa died after an accidental fall in hospital on 12 May 2013, which hastened death from terminal disease. The principal concerns were staff confusion about falls-risk classification and management, inadequate training for a junior doctor, limited sharing of the hospital root cause analysis, and non-mandatory attendance at falls-prevention seminars.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure staff competence in managing patients after falls

    Wider context from the report

    “4. The junior doctor present did not know how to deal with a patient post fall on the ward, though he had dealt with patients in the emergency unit who had fallen in the community. He had not attended the hospital training seminar on falls. 5. The hospital root cause analysis was not shared with all relevant members of staff, though it was signed off at the beginning of August. Thus learning points from it were completely lost to some. I heard that a great deal of work is being done in your trust to attempt to prevent falls and appropriately to treat patients when falls have occurred, but attendance at one of the monthly seminars run by the lead doctor for falls is not mandatory for all staff. ”

    Source location

    Agostino COSTA · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Blackpool and the Fylde

    AI-generated summary

    Ethel Cross · 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

    Ethel Cross, who had a history of falls, fell on ward 4 at Clifton Hospital when a wheeled chair slipped, suffering a fractured neck of femur, and died the following day. Concerns were raised about wheeled chairs being accessible to elderly patients at risk of falls and the lack of an available alarm to alert staff when a high-risk patient mobilised unsupported.

    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

    Presence of wheeled chairs in areas accessible to elderly patients at significant risk of falls

    Wider context from the report

    “During the Inquiry, I received evidence that chairs utilised by staff which have wheels attached to them had been present on ward 4 and that Ethel Cross had sat on one of these chairs which slipped and she suffered a fracture. I heard evidence that these chairs have been removed from two wards – including ward 4 - on which elderly patients at significant risk of falls may be cared for. I am concerned that such chairs may continue to be present on other wards within the Trust where such patients may have access to them and similar incidents may occur. ”

    Source location

    Ethel Cross · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Inner North London

    AI-generated summary

    John William Wright · 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 William Wright, who had a history of paranoid schizophrenia and COPD, was admitted to hospital with pneumonia and suffered several falls, including a fall that caused a fractured spine and left humerus. He died on 15 April 2013 from recurrent chest infections; the inquest concluded that his death resulted from an accident. Concerns included the lack of investigation into the cause of the fall and uncertainty about whether all relevant staff were trained in falls protocols and recording requirements.

    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 the causes or potential causes of falls

    Wider context from the report

    “1. There was no investigation of the cause or potential cause of the fall (whether there were any external factors involved – water on the floor, over-cleaning or any other high risk matter) so as to ensure that further falls could be prevented if necessary. Even if it transpired that the cause could not be determined, the fall should have been treated as a Serious Untoward Incident that warranted some kind of investigation. The North Middlesex University Hospital NHS Trust Serious Incident Policy defines as ‘serious’ an ‘Accident while in hospital’ and I consider that such a fall should be considered to be an accident. The policy then details actions that should be taken by staff dependent on the urgency of the incident and the evidence that I was given confirmed that the appropriate electronic records were not made following the incident. 2. It was not at all clear from the evidence whether the training on falls policy and the protocols related to the recording of witnessed falls extended to the doctors as well as nurses and it is clear that, as a fall may be witnessed by any staff member at a hospital, the proper protocols should at least be known even if access to electronic means of recording an incident is limited for reasons of confidentiality. ”

    Source location

    John William Wright · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026