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.
South Yorkshire (Eastern)
Concerns raised1
Failure to keep adequate records of falls care
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
There is no record or evidence that the patient experienced a fall during admission.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The Trust disputes that Mr Horton experienced a fall during admission, stating that no record or evidence of a fall exists.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Somerset
Concerns raised3
Failure to address gaps in the falls risk assessment and management process for patients admitted from care homes
Failure to complete falls risk assessments within the first 24 hours of ward admission
Lack of falls risk mitigation measures
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Require falls risk assessments within 12 hours of admission, with weekly or condition-triggered reviews, and display patient risk status at the bedside.
Stated by Somerset NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 September 2025.
Action
Monitor falls risk assessment compliance through monthly Core Nursing Metrics audits and additional spot audits.
Stated by Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 September 2025.
Action
Use an acute medical unit admission checklist to contact families, care homes or community hospitals and gather baseline information for risk mitigation.
Stated by Somerset NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 September 2025.
Action
Improve Intentional Rounding through role modelling, a patient-centred real-time documentation tool and rollout of the new form across the acute medical unit.
Stated by Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 September 2025.
Action
Allocate medical matrons 20% of weekly time to clinical ward work supporting training, high-risk patient identification, ward rounds and safety huddles.
Stated by Somerset NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 September 2025.
Action
Review reported incidents daily and verify that measures and steps have been taken to mitigate further patient harm.
Stated by Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 September 2025.
County Durham and Darlington
Concerns raised2
Failure to put recommended falls prevention equipment in place
Reluctance to provide adequate resources for falls prevention equipment
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
Provide 12 working sensor mats and fall-detection equipment for service users.
Stated by Williams & Spenceley LimitedStated completedThe respondent said that this action was complete when they made their response on 17 July 2025.
Action
Impose registration conditions requiring the provider to safeguard residents from falls, confirm suitable equipment is in place, and update care plans.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 17 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
The report’s claim that sensor mats were not purchased or available is disputed as inaccurate.
Stated by Williams & Spenceley LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing fall sensors and an urgent calling system were considered sufficient to protect service users.
Stated by Williams & Spenceley LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Responsibility for sourcing and implementing recommended falls prevention equipment rests with care home management, not the Council.
Stated by Durham County CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Council was not aware of evidence that the owner specifically refused resources for falls prevention equipment, and observed equipment installed in several bedrooms.
Stated by Durham County CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The provider is best placed to address whether sensor mats should have been supplied for an individual's assessed needs.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Sensor mats provide an early warning enabling swift responses but do not physically prevent falls.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Yorkshire (Eastern)
Concerns raised4
Failure to complete a Datix report following an inpatient fall
Failure to complete a falls assessment within six hours of transfer
Failure to put falls prevention measures in place following the first falls assessment
Failure to document falls prevention measures at the first falls assessment
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.8
Action
Add incident-reporting prompts to the nurse-in-charge checklist to identify and escalate outstanding Datix reports.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Action
Implement a standardised safety-huddle log with falls-prevention prompts and measure compliance and effectiveness during implementation.
Stated by the Rotherham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 June 2025.
Action
Implement a real-time Meditech dashboard showing outstanding and completed risk assessments for nurse-in-charge oversight.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Action
Refresh risk assessments on transfer to a new ward so staff complete them from the patient’s current presentation.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Action
Complete Ward B4’s initial Exemplar Accreditation assessment, including handover and falls-assessment review, in October 2025.
Stated by the Rotherham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 June 2025.
Action
Make falls-prevention documentation mandatory in risk assessments and audit compliance through Tendable.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Action
Recruit and commence a falls lead practitioner to drive Trust-wide falls-prevention improvements, audit clinical effectiveness and identify further quality-improvement work.
Stated by the Rotherham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 June 2025.
Action
Include falls prevention within the Exemplar Accreditation programme and continuously measure ward performance.
Stated by the Rotherham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 June 2025.
Suffolk
Concerns raised1
Failure to implement identified mitigation measures
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Complete a companywide review of residents’ risk assessments, care plans, risk-mitigation actions and communication records.
Stated by Maven HealthcareStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Action
Deliver mandatory falls-prevention, regulatory-responsibility and care-plan-adherence refresher training, with reflective practice for registered nurses.
Stated by Maven HealthcareStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Action
Introduce daily huddles, clinical risk meetings, staff meetings, a weekly clinical risk register and regular management validation visits.
Stated by Maven HealthcareStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Action
Implement electronic PCS sign-off for high-risk plans and critical fall-risk measures.
Stated by Maven HealthcareStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Action
Review safe-bedrail and falls-risk policies and procedures to reflect new systems, processes and initiatives.
Stated by Maven HealthcareStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Action
Cascade revised safe-bedrail and falls-risk policies and procedures across the company.
Stated by Maven HealthcareStated plannedThe respondent said that this action was planned when they made their response on 30 June 2025.
South Wales Central
Concerns raised3
Failure of falls-management materials to address preventive risk identification, assessment and documentation
Lack of an available Falls Prevention Strategy or Policy for resident falls-risk assessments
Failure to analyse, assess and communicate falls notifications to inform ongoing risk assessment and mitigation
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.4
Action
Implement staff guidance for preventing and managing falls in residential care homes.
Stated by Merthyr Tydfil County Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Action
Implement a multifactorial falls risk assessment for relevant adult services users.
Stated by Merthyr Tydfil County Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Action
Implement a post-fall summary process to review individual falls and identify ongoing risks.
Stated by Merthyr Tydfil County Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Action
Implement a new moving and handling risk assessment form for residential care occupants.
Stated by Merthyr Tydfil County Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Adult Social Care is responsible for general falls risk through individual care and moving-and-handling plans; Health and Safety addresses environmental or particular risks.
Stated by Merthyr Tydfil County Borough CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Blackpool and the Fylde
Concerns raised2
Failure to conduct an appropriate post-fall injury assessment
Failure to record all post-fall observation scores
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.8
Action
Implement the EnabLE digital care-planning system for scheduled post-fall observations, alerts and point-of-care recording.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Deliver targeted training and supervision on post-fall documentation, escalation, observation recording and lessons learned from the incident.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Complete NEWS2, RESTORE and sepsis training and themed supervision for recognising deteriorating residents.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Review the falls policy with clinical staff and reinforce procedures for responding and escalating after falls.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Deliver moving-and-handling refresher training covering post-fall procedures and techniques to mitigate falls.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Provide documentation prompt sheets to support completion of post-fall records.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Continue EnabLE drop-in support, documentation audits and remote monitoring for adherence and learning needs.
Stated by Barchester Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025.
Action
Complete induction, including NEWS2 training, for three new bank nurses.
Stated by Barchester Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025.
Cumbria
Concerns raised2
Failure to undertake and evidence appropriate falls risk assessments
Failure to report falls or collapses on the ward
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.4
Action
Complete an urgent assurance check of falls documentation and current AMU patient monitoring.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 June 2025.
Action
Review ward falls assurance evidence against the Trust-wide Falls Improvement Plan and ward SMART plans.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 June 2025.
Action
Revise the FRAMP policy to mandate reassessment after sedation, deterioration or procedures and reinforce prompt documentation.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 June 2025.
Action
Deliver refresher incident-reporting training to AMU nursing staff covering falls, collapses, unwitnessed incidents and reporting thresholds.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 June 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
FRAMP falls assessments were completed and updated appropriately; the identified failure concerned documenting and applying mitigating controls.
Stated by North Cumbria Integrated Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised1
Failure to record significant post-fall injuries in care notes
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.
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
Deliver mandatory refresher training on falls, head-injury recognition, recording, and escalation protocols to all care staff.
Stated by Daryel CareStated completedThe respondent said that this action was complete when they made their response on 31 March 2025.
Action
Enhance digital photographic injury-upload capability, obtaining explicit client consent in accordance with policy, to supplement written care-note descriptions.
Stated by Daryel CareStated plannedThe respondent said that this action was planned when they made their response on 31 March 2025.
Action
Update care-documentation guidance and training with structured prompts for detailed injury descriptions and recording the rationale for non-escalation after initial reporting.
Stated by Daryel CareStated plannedThe respondent said that this action was planned when they made their response on 31 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The fall and developing injury were recorded in care notes, and the head injury was escalated promptly to the multi-disciplinary team.
Stated by Daryel CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No inappropriate “No concerns” entry attributable to staff was found in the official electronic care records, so its origin and context cannot be confirmed.
Stated by Daryel CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Daryel Care reported the fall to Adult Social Care, while ambulance attendance and hospital treatment had already addressed the immediate response.
Stated by London Borough of IslingtonDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Northumberland
Concerns raised1
Misunderstanding of peripheral vision and witnessed or unwitnessed falls
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 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
Brief Ward 9 clinical staff on accurate witnessed and unwitnessed fall terminology and its use in incident reporting and communications.
Stated by Northumbria Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.
Action
Revise the Integrated Falls Prevention Policy to define witnessed and unwitnessed falls, remove peripheral vision terminology, and replace it with line-of-sight wording.
Stated by Northumbria Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
Action
Disseminate the revised falls policy through governance approval, staff training, communications bulletins, meetings, safety huddles, and mandatory refresher training.
Stated by Northumbria Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
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Includes assessment, care planning, equipment, supervision, handover, referral, reporting, post-fall response and assurance explicitly dedicated to falls risk.
