First reported 31 Oct 2013•Latest report 21 May 2026
Definition
What this concern includes
Includes assessment, care planning, equipment, supervision, handover, referral, reporting, post-fall response and assurance explicitly dedicated to falls risk.
Not included
Generic mobility, staffing or environmental failures not explicitly tied to falls
The occurrence of a fall without an identified control deficiency
Falls from windows where the asserted control is the design or restriction of the window
Reports
165
Distinct published reports
Individual concerns
285
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
349
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care14
Care Quality Commission9
Barts Health NHS Trust6
Office of the Chief Coroner5
Aneurin Bevan University LHB4
Manchester University NHS Foundation Trust4
Royal London Hospital4
University Hospitals Sussex NHS Foundation Trust4
East Kent Hospitals University NHS Foundation Trust3
Hc-One Limited3
Swansea Bay University Local Health Board3
University Hospitals Birmingham NHS Foundation Trust3
Barchester Healthcare Limited2
Borough Care Ltd2
Cardiff & Vale University LHB2
NHS trust65
Healthcare site22
Residential care home21
Nursing home19
Private limited company16
Ministerial department14
Type not available11
Health and social care service regulator9
Local health board9
English metropolitan district council7
Multi-service care provider7
Care-home operator5
Coronial office5
English county council5
Executive non-departmental public body4
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Nottinghamshire
Concerns raised2
Lack of signage highlighting the risk of fall
Lack of fall protection below the mezzanine openings
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Place no-unauthorised-access signage beside the gate.
Stated by Urbn UK LimitedStated completedThe respondent said that this action was complete when they made their response on 6 September 2019.
Action
Replace the scaffolding with high railings throughout.
Stated by Urbn UK LimitedStated completedThe respondent said that this action was complete when they made their response on 6 September 2019.
Action
Infilling the voids with steel plates.
Stated by Urbn UK LimitedStatus unclearThe respondent did not make the status of this action clear when they made their response on 6 September 2019.
Gloucestershire
Concerns raised2
Insufficient consideration of falls prevention measures on the surgical ward
Insufficient understanding of the post-falls protocol on the surgical ward
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Train Trust nursing staff in falls assessment, prevention, documentation and post-fall management, with mandatory and educational refreshers.
Stated by Gloucestershire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.
Action
Undertake the Silver quality-improvement project to improve identification of individual falls risks and consistent use of preventative measures through the Safety Hour Checklist.
Stated by Gloucestershire Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2019.
East London
Concerns raised6
Lack of care plans addressing identified high fall risk
Failure to report multiple falls to the care commissioner
Failure to encourage wheelchair seatbelt use after falls
Failure to investigate subsequent falls
Failure to encourage compliance with wheelchair-fall prevention measures
Failure to plan measures to prevent wheelchair 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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Implement organisation-wide multifactorial falls risk assessments, including reassessment, care planning, documentation and review requirements.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.
Action
Develop and provide a post-fall protocol flow chart and checklist to guide staff through required actions, documentation and investigation.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Falls among older people cannot always be prevented, although risks can be minimised and staff responses improved.
Stated by Hc-One LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to complete falls risk assessments in accordance with Trust requirements
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.
East London
Concerns raised1
Failure to provide falls-management equipment before discharge
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Ensure essential discharge equipment is provided and installed before discharge, with provision checked through the discharge checklist.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Monitor discharge-checklist completion through Ward Manager oversight.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Milton Keynes
Concerns raised1
Unavailability of a home-based falls response service
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Operate a 24/7 Home 1st Rapids service providing rapid triage, home attendance, assessment and escalation for acute falls.
Stated by NHS Central East Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing commissioned services sufficiently replace the discontinued falls service, covering acute, preventative and non-urgent community fall needs.
Stated by NHS Central East Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Birmingham and Solihull
Concerns raised5
Inadequate assurance of wheelchair-fall risk management
Undated and unsigned falls risk management and assessment documents
Reliance on staff presence to prevent falls
Inadequate completion of falls risk assessments
Reliance on staff intervention during wheelchair 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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Implement wheelchair risk assessments and lap-belt protocols, brief staff, provide care-folder access, and monitor compliance through management oversight.
Stated by Cole Valley Nursing HomeStated completedThe respondent said that this action was complete when they made their response on 26 May 2019.
Action
Introduce and complete comprehensive Falls Risk Assessments for all residents, with monthly or condition-triggered recalculation.
Stated by Cole Valley Nursing HomeStated completedThe respondent said that this action was complete when they made their response on 26 May 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Implemented control measures are considered sufficient to resolve the identified falls, wheelchair restraint and investigation concerns.
Stated by Cole Valley Nursing HomeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester North
Concerns raised2
Failure to update and complete critical risk assessments
Failure to adhere to falls prevention policy and protocol
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Yorkshire (Western)
Concerns raised2
Failure to conduct falls risk assessments regularly
Failure to follow falls risk assessments and care plans
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.
Manchester North
Concerns raised5
Failure to refer people at high risk of falls to the falls prevention team
Failure to undertake falls prevention care plans
Failure to provide falls prevention equipment
Failure to undertake falls risk assessments
Failure to identify people at high risk of falls
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Implement a falls matrix to monitor falls and support referrals to the falls team when required.
Stated by Beechwood LodgeStated completedThe respondent said that this action was complete when they made their response on 25 April 2019.
Action
Refer all falls-risk concerns to appropriate professionals, including doctors and falls teams.
Stated by Beechwood LodgeStated completedThe respondent said that this action was complete when they made their response on 25 April 2019.
Action
Add safety-equipment risk assessments to care plans, including whether equipment is used and reasons for non-use.
Stated by Beechwood LodgeStated completedThe respondent said that this action was complete when they made their response on 25 April 2019.
Action
Strengthen risk assessments for residents who have experienced falls.
Stated by Beechwood LodgeStated completedThe respondent said that this action was complete when they made their response on 25 April 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Falls-prevention equipment was considered inappropriate because of trip hazards from extremely poor eyesight, with the existing call bell enabling assistance when required.
Stated by Beechwood LodgeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes assessment, care planning, equipment, supervision, handover, referral, reporting, post-fall response and assurance explicitly dedicated to falls risk.
