Recurring concern
Inadequate control of falls risks
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Request correctionFirst reported 31 Oct 2013•Latest report 21 May 2026
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
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure of the access-ladder fall protection to prevent 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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to provide falls-risk wristbands for patients at risk of falling
This report raised 24 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to carry out falls risk assessments on readmission and after successive 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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to prevent falls among patients identified as being at high risk of falling
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Inaccurate nursing staff belief that 1:1 nursing care is unavailable for falls risk or physical care needs
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Subjective prioritisation of response to falls detection device activation
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised3
Omissions in documentation and record keeping of falls and changes in residents’ condition
Failure to review falls risk assessments and refer recurrent falls back to the Falls Service
Failure of alarm signals to distinguish falls-sensor activation from handheld-buzzer requests for assistance
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of a presumption of increased falls risk for certain classes of patients in falls risk assessments
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to accurately record previous falls in 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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to communicate the patient's total number of falls to all visiting staff
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 concernsEach 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
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Action
Revise and publish the falls policy and post-falls checklist to specify NICE-based neurological observation frequency and duration after suspected or confirmed head injury.
Stated by Royal Devon University Healthcare NHS Foundation Trust -
Action
Require falls risk and falls information in bedside handovers and safety briefings, with observational audits, feedback, and re-audit of information-sharing gaps.
Stated by Royal Devon University Healthcare NHS Foundation Trust -
Action
Implement filing of post-falls checklists with physiological and neurological observation charts for daily multidisciplinary team review of patients’ multiple falls.
Stated by Royal Devon University Healthcare NHS Foundation Trust
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Action
Issue and disseminate a Trust-wide Patient Safety Alert covering neurological observations, post-falls checklist completion and filing, and inclusion of falls information in briefings and handovers.
Stated by Royal Devon University Healthcare NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The recommended safety actions are primarily the responsibility of the hospital trust.
Stated by DRS GIBB MURCH GILLARD BOWYER & GEARY
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Position
The hospital trust’s action plan is considered to satisfactorily address all concerns and recommended actions.
Stated by DRS GIBB MURCH GILLARD BOWYER & GEARY
Data last updated 7 September 2026