Recurring concern

Inadequate control of falls risks

Get email alerts

Request correction

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.

17 Nov2014
West Yorkshire (East)
Concerns raised1
1. Failure to undertake regular falls assessments for residents
This report raised 15 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 Gladys Smith · 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 Gladys Smith died while resident at a care home; the supplied text does not provide further circumstances of her death. The concerns included failures in repositioning, bruise and wound monitoring, falls assessment, weight and nutrition monitoring, dementia care, and delays or gaps in district nursing wound documentation and referral. The report also identified a lack of comprehensive national guidance on wounds and ulcers caused by impact injuries.

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 regular falls assessments for residents
Wider context from the report
“(d) Falls assessments in respect of Mrs Smith whilst a resident at the Care Home were not regularly undertaken and no consideration was at any time given by Care Home staff as to the most appropriate location for Mrs Smith's room within the Care Home. In the circumstances, falls assessments should be regularly undertaken in respect of all residents and regular consideration should be given as to the appropriate location of residents' rooms within the Care Home; ”
Source location
Mrs Gladys Smith · Prevention of Future Deaths report
Page 1 · concerns
Open source report
31 Oct2014
Brighton and Hove
Concerns raised1
1. Failure to complete emergency department nursing documentation and falls assessment
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 2
1. Action
  Provide further documentation training through departmental nurse induction and nurse development training days.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
2. Action
  Conduct regular audits to ensure Short Stay Ward and Clinical Decisions Unit proformas are used correctly.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
AI-generated summary

Maureen Annette ELLETT · 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 report concerns the death of Maureen Annette ELLETT; the circumstances are referred to the Record of Inquest. Concerns included incomplete emergency department documentation and observations, inadequate clinical planning and review, staffing and fatigue issues, and shortcomings in ECG and observation procedures. The report states that the cumulative effect of these issues was considered catastrophic by the inquest.

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 emergency department nursing documentation and falls assessment
Wider context from the report
“(4) The second Triage Nurse in A & E did the assessment on Mrs. Ellett at the end of a 12½ hour shift which was due to end at 20:00 hours on the 16th June, 2014. She saw Mrs. Ellett at approximately 19:20 hours and out of the two pages of emergency department Nursing Documentation which require over 80-pieces of information recorded, she recorded merely 12 pieces of information. The Falls Risk Assessment was completely blank and yet Mrs. Ellett was at high risk of falls and should have been provided with a green wrist band to alert all staff to this. It is thought that this shift is too long and at the end of it, staff who have had no proper breaks will be exhausted. It is considered that all staff should be trained on the importance of completing hospital documentation. ”
Source location
Maureen Annette ELLETT · 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
Provide further documentation training through departmental nurse induction and nurse development training days.

Verbatim wording from the response
“4. We have established that the triage nurse to whom you refer handed over to her colleague starting the next shift that there were several outstanding assessments to be completed and documented for Mrs Ellett. We deeply regret that this next member of staff, who had newly come on duty, did not complete these tasks as he should have done. We have not been able to take this up with him in the light of your comments as he had already left the Trust before Mrs Ellett’s inquest took place. Arrangements have been made for further training on documentation to be included in both the departmental nurse induction programme and also in the nurse development training days held in the department.”

Source location
2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 31 October 2014
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 regular audits to ensure Short Stay Ward and Clinical Decisions Unit proformas are used correctly.

Verbatim wording from the response
“The nursing and medical staff in the Emergency Department, as well as the locum staff involved in the care of Mrs Ellett, and we ourselves have taken very seriously all the issues you have raised, and changes have been made to improve different aspects of the quality of care. As an over-arching step, individual named emergency consultants have recently been given responsibility for each of the Short Stay Ward and Clinical Decisions Unit, in order to provide visible senior medical leadership in each area and to seek ways of improving the quality of care. This will include regular audit to ensure proformas are being used correctly.”

Source location
2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 4 · response
Published 31 October 2014
Open published response
9 Oct2014
North Northumberland
Concerns raised1
1. Lack of an entrance lobby or passageway to arrest falls from communal stairs
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

Stephen Peter Simpson · 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

Stephen Peter Simpson appears to have fallen down communal concrete stairs on 13 March 2014 and struck his head on an external door, later dying in hospital from a skull fracture and brain haemorrhage. The concerns were that the building had no lobby or passageway to arrest a fall and that the smooth concrete stairs lacked a non-slip surface, leaving a risk of serious injury or death from impact with the door.

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 an entrance lobby or passageway to arrest falls from communal stairs
Wider context from the report
“The design of the building is that there is no entrance lobby or passageway to arrest any accidental fall, with the result that any person who slips or falls while negotiating the communal stairs is liable to sustain serious injury from making impact with the solid external door. Additionally, the stairs are constructed of smooth concrete without the addition of any non-slip surface. Even if a non-slip surface was present, this would not obviate the risk of serious injury or death from impact with the external door, if a person falls from the stairs. ”
Source location
Stephen Peter Simpson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
12 Sep2014
Carmarthenshire and Pembrokeshire
Concerns raised2
1. Failure to carry out risk assessments identifying falls risk
2. Unavailability of low beds for patients at risk of 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.

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

Mr Page · 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

Mr Page was admitted to hospital after a fall, underwent surgery, and later fell from his bed, fracturing his cervical spine; his condition deteriorated and he died on 2 May 2014. Concerns included the absence of a falls risk assessment and low bed, communication needs after handover, and the provision of sufficient nursing staff when greater staffing levels were required.

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 carry out risk assessments identifying falls risk
Wider context from the report
“2. No risk assessment was carried out on Mr Page identifying the risk of falls. ”
Source location
Mr Page · 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
Unavailability of low beds for patients at risk of falls
Wider context from the report
“3. There was no low bed available to Mr Page. ”
Source location
Mr Page · Prevention of Future Deaths report
Page 1 · concerns
Open source report
12 Sep2014
North Wales (East and Central)
Concerns raised2
1. Failure to obtain further falls risk assessments when residents’ condition is declining
2. Failure to reassess and update care plans and falls risks after hospital return
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

Sybil Roberts · 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

Sybil Roberts fell at her care home on 30 December 2013 and again on 1 February 2014, sustaining a fractured hip on each occasion before dying at Maelor Hospital Wrexham on 15 March 2014. The investigation identified that a further falls risk assessment had not been undertaken, and that her care plan and falls risk had not been reassessed and updated before her return from hospital, after which she sustained her second fracture two days later.

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 obtain further falls risk assessments when residents’ condition is declining
Wider context from the report
“During the course of the investigation it became apparent that although Mrs Roberts had been assessed upon her admission to the residential home, there had not been a referral to her GP (as would be normal practice at this home) for a further falls risk assessment. This is despite an acknowledgement that her condition was declining prior to the first fall. Furthermore her care plan and falls risk had not been reassessed and updated prior to her return to the home from hospital after the first fall and she sustained her second fracture only two days later. An inadequate assessment of the potential risks Mrs Roberts was made and I feel it is necessary to bring this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death. ”
Source location
Sybil Roberts · 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 reassess and update care plans and falls risks after hospital return
Wider context from the report
“During the course of the investigation it became apparent that although Mrs Roberts had been assessed upon her admission to the residential home, there had not been a referral to her GP (as would be normal practice at this home) for a further falls risk assessment. This is despite an acknowledgement that her condition was declining prior to the first fall. Furthermore her care plan and falls risk had not been reassessed and updated prior to her return to the home from hospital after the first fall and she sustained her second fracture only two days later. An inadequate assessment of the potential risks Mrs Roberts was made and I feel it is necessary to bring this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death. ”
Source location
Sybil Roberts · Prevention of Future Deaths report
Page 1 · concerns
Open source report
3 Sep2014
Surrey
Concerns raised4
1. Failure to complete the falls management plan
2. Delays in putting falls-prevention measures into place
3. Delays in reviewing and reassessing falls risk
1. Failure to accurately identify falls 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.

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

Hilda Florence Thompson · 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

Hilda Florence Thompson, who had limited mobility and a history of falls, was admitted to hospital with breathlessness and later identified as a high falls risk. She collapsed on 19 January 2014, sustained an extensive intracranial injury, and died on 22 January 2014; concerns included an incomplete admission management plan, incorrect initial identification as not being at risk of falls, delayed falls assessment, and poor record-keeping.

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 the falls management plan
Wider context from the report
“• Upon her admission to hospital, her management plan was not completed and she was wrongly identified as not being a falls risk. • There was no further review of Mrs Thompson and it was not until 11/1/14 when a full falls risk assessment was made and preventable measures put into place. • Poor note taking of 2/1/14 to account for this. • This left a gap of some 10 days during which she was not properly risk assessed for falls. ”
Source location
Hilda Florence Thompson · 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
Delays in putting falls-prevention measures into place
Wider context from the report
“• Upon her admission to hospital, her management plan was not completed and she was wrongly identified as not being a falls risk. • There was no further review of Mrs Thompson and it was not until 11/1/14 when a full falls risk assessment was made and preventable measures put into place. • Poor note taking of 2/1/14 to account for this. • This left a gap of some 10 days during which she was not properly risk assessed for falls. ”
Source location
Hilda Florence Thompson · 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
Delays in reviewing and reassessing falls risk
Wider context from the report
“• Upon her admission to hospital, her management plan was not completed and she was wrongly identified as not being a falls risk. • There was no further review of Mrs Thompson and it was not until 11/1/14 when a full falls risk assessment was made and preventable measures put into place. • Poor note taking of 2/1/14 to account for this. • This left a gap of some 10 days during which she was not properly risk assessed for falls. ”
Source location
Hilda Florence Thompson · 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 accurately identify falls risk
Wider context from the report
“• Upon her admission to hospital, her management plan was not completed and she was wrongly identified as not being a falls risk. • There was no further review of Mrs Thompson and it was not until 11/1/14 when a full falls risk assessment was made and preventable measures put into place. • Poor note taking of 2/1/14 to account for this. • This left a gap of some 10 days during which she was not properly risk assessed for falls. ”
Source location
Hilda Florence Thompson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
29 Aug2014
Inner North London
Concerns raised1
1. Failure to record post-fall neurological observations
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
  Include documentation and falls management in induction for new medical trainees.
  Stated by Barts Health NHS TrustStated completed
2. Action
  Hold twice-daily safety briefings highlighting the Trust falls protocol.
  Stated by Barts Health NHS TrustStated planned
3. Action
  Remind nursing staff that the nurse in charge is responsible for following and documenting the correct falls procedure.
  Stated by Barts Health NHS TrustStated completed
1. Action
  Provide nurses with neurological-observation training through the Critical Care Outreach Team.
  Stated by Barts Health NHS TrustStated in progress
2. Action
  Audit nurses’ falls-policy understanding, care-plan documentation, neurological-observation understanding, and competence in performing neurological observations.
  Stated by Barts Health NHS TrustStated planned
Respondent positions 1
1. Position
  Appropriate neurological observations were carried out after the fall; the missing chart was inadvertently misfiled.
  Stated by Barts Health NHS TrustDisputes the concern
AI-generated summary

Irshad ALI · 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

Irshad Ali was admitted to hospital for drainage of ascites, fell unwitnessed on the ward on 25 March 2014, and later returned with a massive head injury. He died six weeks later following a consequent chest infection. Concerns included missing records of intentional rounding and neurological observations, required pre-discharge checks not being completed, and communication problems around his discharge.

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 post-fall neurological observations
Wider context from the report
“2. Though the senior sister looking after Mr Ali on the morning of 25 March assured me that neurological observations were carried out hourly after his fall, there was no record of this. Again, the chart appears to have gone missing. ”
Source location
Irshad ALI · 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 documentation and falls management in induction for new medical trainees.

Verbatim wording from the response
“Senior medical staff have confirmed that the induction for new medical trainees now includes a section on documentation and management of falls, emphasising the requirement to document actions in the medical records.”

Source location
2014-0387-Response-by-Barts-Health-NHS-Trust
Page 1 · response
Published 29 August 2014
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
Hold twice-daily safety briefings highlighting the Trust falls protocol.

Verbatim wording from the response
“To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.”

Source location
2014-0387-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 29 August 2014
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 nursing staff that the nurse in charge is responsible for following and documenting the correct falls procedure.

Verbatim wording from the response
“To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.”

Source location
2014-0387-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 29 August 2014
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 nurses with neurological-observation training through the Critical Care Outreach Team.

Verbatim wording from the response
“To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.”

Source location
2014-0387-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 29 August 2014
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
Audit nurses’ falls-policy understanding, care-plan documentation, neurological-observation understanding, and competence in performing neurological observations.

Verbatim wording from the response
“To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.”

Source location
2014-0387-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 29 August 2014
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
Appropriate neurological observations were carried out after the fall; the missing chart was inadvertently misfiled.

Verbatim wording from the response
“The missing neurological observation chart has been located and it confirms that appropriate neurological observations were carried out after Mr Ali’s fall. This chart had been inadvertently misfiled.”

Source location
2014-0387-Response-by-Barts-Health-NHS-Trust
Page 1 · response
Published 29 August 2014
Open published response
25 Jul2014
West Yorkshire (Western)
Concerns raised1
1. Delays in implementing measures identified to minimise falling 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.

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

Edna Bulmer · 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

Edna Bulmer, who had a history of falls, suffered an unwitnessed fall on 10 September 2013 and was later found unconscious in bed. She died in hospital on 15 September 2013 after sustaining a serious intracranial haemorrhage. The concerns identified were inconsistent recording of her falls risk, delays in providing the identified pressure mat and pendant, and the apparent absence of a clear process for reviewing her risk assessment after further 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
Delays in implementing measures identified to minimise falling risk
Wider context from the report
“(2) The measures identified within the Personal Risk Assessment to minimise risk were not implemented (provision of mat and pendant) until several days after Mrs. Bulmer’s arrival, after a number of incidents had occurred. ”
Source location
Edna Bulmer · Prevention of Future Deaths report
Page 2 · concerns
Open source report
8 Jun2014
Wirral
Concerns raised1
1. Lack of a replacement measure protecting elderly patients at risk of falls
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

James McArdle · 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

James McArdle was an elderly independent man admitted to hospital on 24 November 2013 who suffered two falls on 5 December 2013, the second resulting in a non-survivable condition. The concern was that a coloured wristband system identifying patients at risk of falls had been withdrawn without replacement, potentially removing protection for elderly patients at risk of falling.

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 replacement measure protecting elderly patients at risk of falls
Wider context from the report
“That whatever the thinking was as regards the merits of the coloured wrist band system, the system has been withdrawn and not replaced, and in the process a level of protection against elderly patients at risk of falling suffering a fall has been removed. I am concerned that unless a review is undertaken and some new measure(s) introduced then patients such as the Deceased may be at a heightened risk of falls and future deaths may result. ”
Source location
James McArdle · Prevention of Future Deaths report
Page 1 · concerns
Open source report
5 Jun2014
Manchester South
Concerns raised1
1. Failure to update falls risk and bed rails assessments in accordance with policy
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 1
1. Action
  Monitor completion and updating of nursing risk assessments through daily matron rounds, ward-manager oversight and out-of-hours compliance reviews.
  Stated by Manchester University NHS Foundation TrustStated completed
AI-generated summary

THOMAS PATRICK MAHER · 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

Thomas Patrick Maher fell on a ward at Trafford General Hospital on 3 February 2014 and fractured his acetabulum. The report identified concerns about missing clinical records, assessments and alarm arrangements relating to falls risk, delays and problems in transferring him between hospitals, ward placement, medication administration, notification of next of kin, and the transfer of patient notes. The investigation recorded the medical cause of death as chest sepsis, hospital-acquired pneumonia and a left acetabulum fracture of the hip, with other conditions also listed.

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 update falls risk and bed rails assessments in accordance with policy
Wider context from the report
“2. On a number of occasions during his stay in the hospital, the falls risk assessment and the bed rails assessment were not updated per policy. ”
Source location
THOMAS PATRICK MAHER · 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
Monitor completion and updating of nursing risk assessments through daily matron rounds, ward-manager oversight and out-of-hours compliance reviews.

Verbatim wording from the response
“The Head of Nursing for Trafford has taken steps to address this issue and has established robust monitoring processes. Matrons undertake daily rounds of the ward areas and review the completion of all nursing documentation; this review focuses specifically on the completion of appropriate risk assessments and helps raise awareness with staff. Ward Managers also have responsibility for ongoing monitoring of compliance in their areas. In addition, the Out of Hours team review compliance with the completion and updating of risk assessments at night and at weekends with any non-compliance being addressed at the time with the individuals concerned and highlighted to the Ward Manager or Matron.”

Source location
2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Page 2 · response
Published 5 June 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to undertake regular falls assessments for residents

Concerns raised1

Failure to complete emergency department nursing documentation and falls assessment

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

Lack of an entrance lobby or passageway to arrest falls from communal stairs

Concerns raised2

Failure to carry out risk assessments identifying falls risk

Unavailability of low beds for patients at risk of falls

Concerns raised2

Failure to obtain further falls risk assessments when residents’ condition is declining

Failure to reassess and update care plans and falls risks after hospital return

Concerns raised4

Failure to complete the falls management plan

Delays in putting falls-prevention measures into place

Delays in reviewing and reassessing falls risk

Failure to accurately identify falls risk

Concerns raised1

Failure to record post-fall neurological observations

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

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

Concerns raised1

Delays in implementing measures identified to minimise falling risk

Concerns raised1

Lack of a replacement measure protecting elderly patients at risk of falls

Concerns raised1

Failure to update falls risk and bed rails assessments in accordance with policy

Actions described in response 2

Actions described in response 5

Respondent positions 1