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 Wales Central
Concerns raised1
Lack of confidence among nursing staff and healthcare support workers in the use and implications of 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 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
Continue rolling out falls prevention and management training, including preceptorship and healthcare support worker induction, while monitoring compliance.
Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 17 March 2025.
Action
Maintain the Falls Strategy Lead role to coordinate falls training and related improvement work.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 17 March 2025.
Action
Operate the digital multifactorial falls risk assessment within the Welsh Nursing Care Record at St David’s Hospital.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 17 March 2025.
Action
Lead a proposal to update the digital multifactorial falls risk assessment to simplify completion and strengthen risk-reduction actions.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 17 March 2025.
Birmingham and Solihull
Concerns raised2
Failure to update falls prevention risk assessments after falls and deterioration in condition
Inadequate investigation of post-fall incidents
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.4
Action
Update falls risk assessments within 24 hours and document follow-up in care records.
Stated by Care Home ManagerStated completedThe respondent said that this action was complete when they made their response on 3 March 2025.
Action
Hold staff meetings reinforcing accurate incident assessment, timely reporting and compliance with policy and guidance.
Stated by Care Home ManagerStated completedThe respondent said that this action was complete when they made their response on 3 March 2025.
Action
Implement a documentation lead role to oversee falls and risk assessments, with monthly accident audits and timely responses.
Stated by Care Home ManagerStated completedThe respondent said that this action was complete when they made their response on 3 March 2025.
Action
Implement root-cause analysis and incident-investigation tools for falls.
Stated by Care Home ManagerStated completedThe respondent said that this action was complete when they made their response on 3 March 2025.
Manchester South
Concerns raised2
Unavailability of height-adjustable hospital beds for patients cared for on Emergency Department trolleys
Inconsistent falls risk management in Emergency Departments
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.
Inner North London
Concerns raised1
Wider staff skills and knowledge deficit affecting post-fall care
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.2
Action
Provide falls-protocol and post-fall-management education through junior-doctor induction and ongoing nursing and medical team education.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 February 2025.
Action
Deliver regular falls-prevention simulation training, including protocol, post-fall management, documentation, escalation and prevention, to nursing and medical staff.
Stated by Royal Free London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 February 2025.
Hertfordshire
Concerns raised1
Failure of bridge safety measures to meet current guidance for preventing pedestrian jumping or falling
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
Liaise with Network Rail and undertake Principal Inspections of both bridges to assess their structural condition.
Stated by Hertfordshire County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2025.
Action
Use the inspection findings to assess the feasibility and costs of raising or replacing the parapets and consider the appropriate improvement options.
Stated by Hertfordshire County CouncilStated plannedThe respondent said that this action was planned when they made their response on 17 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Parapet heights cannot safely be raised until inaccessible structural areas are assessed using up-to-date condition information.
Stated by Hertfordshire County CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Closing the footbridge is not considered a safer response because diversion could increase unsafe pedestrian crossings and exacerbate isolation.
Stated by Hertfordshire County CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Bridge inspections require Network Rail permission, railway closure and overhead power isolation before feasibility of parapet improvements can be assessed.
Stated by Hertfordshire County CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
County Durham and Darlington
Concerns raised1
Failure to provide effective, individually tailored monitoring measures for residents at high risk of 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.4
Action
Apply the Group Falls Policy and supporting flowcharts covering falls protocols, referrals, care planning, risk assessment and post-fall actions.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Analyse falls incidents monthly, validate home practice through regional reviews and use trend monitoring to identify and address emerging risks.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Remind Home Managers about available falls-reduction equipment and include equipment availability in regular audits of home practice.
Stated by Four Seasons Health Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 13 January 2025.
Action
Review care plans and risk assessments after falls, near misses or other changes in need, updating them where required.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
It cannot be established that Mrs Savage would have responded better to a different sensor measure.
Stated by Four Seasons Health Care GroupDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Yorkshire (Eastern)
Concerns raised1
Failure to provide recommended safety equipment in the home
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.1
Action
Follow up delays in providing recommended aids and equipment for service users.
Stated by City of Doncaster CouncilStated completedThe respondent said that this action was complete when they made their response on 20 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Relevant professionals, rather than social care staff, must assess risks and recommend or order aids and equipment.
Stated by City of Doncaster CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure to follow falls-risk care plans
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
Conduct weekly documentation audits, assurance meetings, metrics reviews and ward action planning across all six divisional wards.
Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 November 2024.
Action
Provide ward-based falls and enhanced-care risk-assessment training with senior-nurse oversight and refresher documentation sessions for staff.
Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 November 2024.
Surrey
Concerns raised3
Failure to provide falls minimisation plans for residents at risk of falls
Failure to provide wearable emergency alert devices to residents not assessed as high risk of falls
Failure of oversight and auditing to identify non-completion of falls minimisation plans
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.9
Action
Complete falls risk assessments and multifactorial assessments and minimisation plans for residents identified as at risk.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Train the General Manager in the organisation’s falls-minimisation protocols and policies.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Cascade further falls-risk training to strengthen staff knowledge and risk-management documentation.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Disseminate updated falls-prevention policies and multifactorial falls-risk screening tools to managers for team implementation.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Hold weekly clinical-risk meetings to analyse incidents, review risks and care plans, and assign actions with ownership and timescales.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Introduce an internal audit framework covering call-bell response times and falls-minimisation plans, with results shared with staff.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Reconfigure the call-bell system to escalate unanswered calls after three minutes to an emergency tone.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Introduce and operate a care-plan tracker with daily management checks and monthly care-record audits.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Conduct Quality Team compliance inspections to oversee audit findings and ensure actions are completed promptly.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The reconfigured call bell system makes wrist-worn emergency watches unnecessary for high-risk residents.
Stated by Avery Healthcare GroupNo action considered necessaryThe respondent said that no further action was needed.
Birmingham and Solihull
Concerns raised1
Failure of post-death investigations to address central issues relating to falls
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.3
Action
Revise nursing witness-statement templates with prompts covering the incident, preceding care, post-fall care and learning.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 October 2024.
Action
Involve specialist nursing leads from the beginning of Coronial investigations and inquest processes.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 October 2024.
Action
Prepare inquest witnesses through individual and group meetings, calls and meetings with instructed solicitors.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 October 2024.
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Includes assessment, care planning, equipment, supervision, handover, referral, reporting, post-fall response and assurance explicitly dedicated to falls risk.
