Recurring concern

Inadequate control of falls risks

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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.

20 Sep2024
Worcestershire
Concerns raised1
1. Failure to document falls prevention measures following falls risk assessments
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review the electronic post-fall record and intervention document and clarify completion expectations.
  Stated by Worcestershire Acute Hospitals NHS TrustStated in progress
2. Action
  Explore barriers to documenting falls interventions on the electronic patient record, take resulting actions and monitor them through the Improving Safety Action Group.
  Stated by Worcestershire Acute Hospitals NHS TrustStated in progress
3. Action
  Distribute guidance on documenting falls interventions in Sunrise.
  Stated by Worcestershire Acute Hospitals NHS TrustStated planned
AI-generated summary

Margaret Rose MAYCROFT · 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

Margaret Rose Maycroft was readmitted to Worcestershire Royal Hospital after falls and was found to have suffered an ischaemic stroke. During her admission, she sustained further falls resulting in a displaced fractured neck of femur, underwent surgery, and later died at Princess of Wales Community Hospital, Bromsgrove, while receiving palliative care. The principal concern was that, although falls risk assessments were completed, no falls prevention measures were documented or put in place, and there was no evidence that this issue had since been addressed.

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 document falls prevention measures following falls risk assessments
Wider context from the report
“2) In respect of each of these falls, Matron ████████ gave evidence that whilst staff in the Emergency Department and the Acute Frailty Unit had completed falls risk assessments, no measures to mitigate that risk, such as might be found in a falls prevention, assessment and intervention plan, were documented in Ms. Maycroft’s notes. This meant that no documented falls prevention measures were put in place for her. 3) Furthermore, I heard no evidence at the inquest which satisfied me that the steps have now been taken to ensure falls prevention measures are now being properly considered and documented in both the Emergency Department and the Acute Frailty Unit at the hospital. ”
Source location
Margaret Rose MAYCROFT · 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
Review the electronic post-fall record and intervention document and clarify completion expectations.

Verbatim wording from the response
“• There are trust wide falls prevention measures in place and work is being undertaken to review the post fall record and intervention document on the electronic patient record and for the expectations around completion to be clarified.”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 2 · response
Published 24 September 2024
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
Explore barriers to documenting falls interventions on the electronic patient record, take resulting actions and monitor them through the Improving Safety Action Group.

Verbatim wording from the response
“• The barriers faced by staff in documenting falls interventions in place on EPR will be explored and actions taken and monitored through Improving Safety Action Group (ISAG)”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 2 · response
Published 24 September 2024
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
Distribute guidance on documenting falls interventions in Sunrise.

Verbatim wording from the response
“• The EPR team will distribute an update on how to document interventions on Sunrise.”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 2 · response
Published 24 September 2024
Open published response
25 Jul2024
East London
Concerns raised1
1. Failure to prevent predictable and avoidable 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.
Respondent positions 1
1. Position
  The Trust is responsible for responding to concerns about its failures and explaining what went wrong.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Elizabeth Grace Holder · 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

Elizabeth Grace Holder, an 88-year-old woman recovering in hospital after surgery for a broken hip, fell while using a commode without supervision and died from a fatal intracerebral bleed. The concerns identified were that the Trust failed to prevent a predictable and avoidable fall and that its governance systems failed to identify care failings or act on factors contributing to her death.

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 prevent predictable and avoidable falls
Wider context from the report
“1. The Trust’s failure to prevent a predictable and therefore avoidable fall which resulted in death. ”
Source location
Elizabeth Grace Holder · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
The Trust is responsible for responding to concerns about its failures and explaining what went wrong.

Verbatim wording from the response
“The report raises concerns over the Barts Health NHS Foundation Trust’s failure to prevent a predictable and therefore avoidable fall which resulted in death. Despite this incident activating the Patient Safety Incident Response Framework (PSIRF) at the Trust, no sub-optimal aspects to Mrs Holder’s care were identified. Thus, there are concerns around the failure of the Trust’s governance systems to:”

Source location
Response from DHSC
Page 1 · response
Published 1 August 2024
Open published response
19 Jul2024
Herefordshire
Concerns raised1
1. Failure to complete falls assessments before routinely erecting bed rails
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 5
1. Action
  Review and update the bedrails policy in line with national patient-safety guidance.
  Stated by Wye Valley NHS TrustStated in progress
2. Action
  Complete an in-depth audit of bedrail-related falls, assessment compliance, bedrail positioning and observation compliance.
  Stated by Wye Valley NHS TrustStated completed
3. Action
  Redesign digital falls, bedrails and observation assessments to simplify and combine their completion.
  Stated by Wye Valley NHS TrustStated in progress
1. Action
  Implement weekly senior-nurse reviews of falls assessments and associated prevention measures in community hospitals.
  Stated by Wye Valley NHS TrustStated completed
2. Action
  Trial securing bedrails in the down position until a registered nurse completes and supports raising the bedrails assessment.
  Stated by Wye Valley NHS TrustStated in progress
AI-generated summary

Rita Howells · 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

Rita Howells was transferred to Bromyard Hospital for rehabilitation and discharge planning, later became confused and agitated, fell from her bed, and was found to have an intracerebral haemorrhage. The concerns identified were that bed rails were routinely erected before a falls assessment, contrary to policy, and that procedures for establishing whether a call bell was working were unsatisfactory.

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 falls assessments before routinely erecting bed rails
Wider context from the report
“(1) Contrary to Policy as advised, bed rails are routinely erected before Falls Assessment ”
Source location
Rita Howells · 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
Review and update the bedrails policy in line with national patient-safety guidance.

Verbatim wording from the response
“Trust bed rails policy The Trust bedrails policy supports staff to ensure the safety of patients using bed rails whilst promoting their independence and respecting their right to make their own decisions about their care. It clearly details how to reduce potential harm to patients caused by falling from beds or becoming trapped in bed rails. It gives guidance to support patients, carers and staff to make individual decisions around the risk of using and not using bed rails and suggests alternatives to the use of bed rails where their use may prove more hazardous to the patient than not using them. The policy gives instruction relating to standardised practice concerning the assessment, supply and fitting of bed rails and clarifies the responsibilities of individuals regarding safe and appropriate use of bed rails in all settings across the Trust.”

Source location
Response from Wye Valley NHS Trust
Page 2 · response
Published 31 July 2024
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
Complete an in-depth audit of bedrail-related falls, assessment compliance, bedrail positioning and observation compliance.

Verbatim wording from the response
“4. Bespoke audit as part of Quality Improvement”

Source location
Response from Wye Valley NHS Trust
Page 3 · response
Published 31 July 2024
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
Redesign digital falls, bedrails and observation assessments to simplify and combine their completion.

Verbatim wording from the response
“As part of the improvements to our digital nurse noting, a review of all assessments (questions, layout, and functionality) has been ongoing for a number of months. A number of changes are being implemented to improve the risk assessments associated with falls, bedrails and level of observation. This will simplify and combine these assessments to ensure completion at the same time. Given the inconsistency with call bell checks a prompt for a check of the call bell has been added to the digital system and additionally as a safety net, the housekeeper will perform a weekly check.”

Source location
Response from Wye Valley NHS Trust
Page 5 · response
Published 31 July 2024
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
Implement weekly senior-nurse reviews of falls assessments and associated prevention measures in community hospitals.

Verbatim wording from the response
“The community hospital settings have implemented ‘Falls Friday’ where the senior nurse reviews all patient falls assessments and ensures they are up to date, accurate and that all measures are in place as per the assessment outcome.”

Source location
Response from Wye Valley NHS Trust
Page 5 · response
Published 31 July 2024
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
Trial securing bedrails in the down position until a registered nurse completes and supports raising the bedrails assessment.

Verbatim wording from the response
“The most recent initiative is a trial of securing bed rails in the down position (with a yellow cable tie) until the bed rails assessment has been completed. The cable ties will be applied once the bed space has been cleaned and can only be removed by a registered nurse who has undertaken the risk assessment that identifies the need for the rails to be raised. The initiative will be monitored through the routine audits outlined above to ascertain whether this results in a reduction in falls and improvement with correct bed rail positioning.”

Source location
Response from Wye Valley NHS Trust
Page 5 · response
Published 31 July 2024
Open published response
19 Jun2024
South Yorkshire (Western)
Concerns raised1
1. Failure to conduct falls risk assessments on admission
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 4
1. Action
  Update admissions, falls prevention and risk-assessment policies to require timely assessment, injury monitoring and medical escalation.
  Stated by SheffcareStated completed
2. Action
  Roll out refresher training on pre-admission assessments, detailed care notes, falls documentation and escalation, using anonymised scenarios and monthly monitoring.
  Stated by SheffcareStated completed
3. Action
  Discuss falls, documentation and escalation requirements with staff through huddles, supervision and management briefings.
  Stated by SheffcareStated completed
1. Action
  Analyse Person-Centred Care falls-assessment data and present findings to the Quality Committee.
  Stated by SheffcareStated in progress
AI-generated summary

Maureen Alison Woollen · 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

Maureen Alison Woollen was discharged to Deerlands Residential Home after being identified as at high risk of falls. She was later found on the floor, developed facial bruising and reduced food and drink intake, and was admitted to hospital with an intracerebral haemorrhage, from which she died; concerns included missed opportunities to seek medical attention, inadequate care-note use, and failure to conduct a falls risk assessment on admission.

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 conduct falls risk assessments on admission
Wider context from the report
“The inquest found there were missed opportunities to conduct a falls risk assessment on Mrs Woollen's arrival to Deerlands Residential home, to seek medical attention when she was found on the floor on 3 October 2023, to seek medical attention when a bruise on her face was noted on 6 October 2023 and to monitor the progression of her bruise. I am concerned there is no process in place to ensure medical attention is promptly sought for residents who require it, that care notes are not fully utilised, especially for the recording of injury and incidents, and that falls risk assessments are not being conducted on admission. ”
Source location
Maureen Alison Woollen · 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
Update admissions, falls prevention and risk-assessment policies to require timely assessment, injury monitoring and medical escalation.

Verbatim wording from the response
“The admissions policy was reviewed and updated on 1 July 2024 to further outline that falls risk assessment are to be completed prior to or on admission to Sheffcare homes. This will include a”

Source location
Reponse from Sheffcare
Page 4 · response
Published 27 June 2024
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
Roll out refresher training on pre-admission assessments, detailed care notes, falls documentation and escalation, using anonymised scenarios and monthly monitoring.

Verbatim wording from the response
“The importance of maintaining care notes was discussed at the Deputy Managers’ meeting on 2 July 2024 [see document 9]. Sheffcare already have sophisticated Person–Centred Software, but this does not appear to have been used effectively at the time of Mrs Woollen’s care. Sheffcare has now improved the training sessions which already focus on the importance of keeping timely and accurate care notes by incorporating within the existing training real and anonymised scenarios to reinforce to staff understanding. The software includes training around ensuring a falls risk assessment is completed on admission. Falls (witnessed or otherwise) must be documented in the Person–Centred Care system and there is a monitoring and tracking section in the notes. This is audited.”

Source location
Reponse from Sheffcare
Page 3 · response
Published 27 June 2024
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
Discuss falls, documentation and escalation requirements with staff through huddles, supervision and management briefings.

Verbatim wording from the response
“Directly after the incident with Mrs Woollen, the service met with staff at Deerland and what is known as “huddles” were carried out [see document 7]. A huddle is an informal meeting at which matters to celebrate as well as concerns are raised directly with staff. The incident with Mrs Woollen was discussed and staff were reminded of the policies in relation to falls risk, documentation, and escalation it has also been part of their mandatory training and discussed in supervisions. [see document 8].”

Source location
Reponse from Sheffcare
Page 3 · response
Published 27 June 2024
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
Analyse Person-Centred Care falls-assessment data and present findings to the Quality Committee.

Verbatim wording from the response
“████████ met with Care Plan Coordinators on 16 July 2024. The Care Plan Coordinator role and remit is to upload the PCS notes from assessment and ensure that all assessments are undertaken. They support the operational management team in building care plans on PCS and ensure care plans are kept under close review. The meeting focussed on ensuring that falls risk assessments are in place prior to admission or on admission day, along with care plan review processes. ████████ is undertaking an analysis of PCS falls assessment data, which will provide additional reassurances that all residents have falls risk assessments in place and any additional information around the management of falls is appropriately reviewed. The initial findings will be presented at the 22 August 2024 Quality Committee meeting, and this will be completed by 31 August 2024.”

Source location
Reponse from Sheffcare
Page 4 · response
Published 27 June 2024
Open published response
4 May2024
Suffolk
Concerns raised2
1. Inadequate handover arrangements for outstanding falls assessments between shifts
2. Inadequate arrangements for highlighting incomplete risk assessments
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
  Apply a six-hour timeframe for completing falls risk assessments after admission or ward transfer.
  Stated by East Suffolk and North Essex NHS Foundation TrustStated completed
2. Action
  Update the Falls Prevention Policy to require moving-and-handling assessments and Falls Prevention Integrated Care Pathways within six hours of admission or ward transfer.
  Stated by East Suffolk and North Essex NHS Foundation TrustStated in progress
3. Action
  Amend the Integrated Patient Record with an updated falls risk assessment proforma specifying the six-hour completion requirement.
  Stated by East Suffolk and North Essex NHS Foundation TrustStated completed
1. Action
  Audit falls documentation through weekly ward-manager checks and monthly Matron quality audits.
  Stated by East Suffolk and North Essex NHS Foundation TrustStated completed
2. Action
  Transition patient record keeping to an electronic system across the Trust by 2025.
  Stated by East Suffolk and North Essex NHS Foundation TrustStated planned
AI-generated summary

Michael John BURKE · 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

Michael John Burke, who had advanced lung disease and COPD, died on 2 February 2023 after developing pneumonia and sustaining a fractured neck of femur in a fall on a hospital ward. The principal concern was that Ipswich Hospital lacked adequate arrangements for completing, highlighting and handing over falls-risk assessments, leaving the assessment incomplete when he fell.

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
Inadequate handover arrangements for outstanding falls assessments between shifts
Wider context from the report
“The Court heard evidence that risk assessments were to be carried out regularly on patients in relation to their falls risk. This is particularly important in circumstances where a patient was being transferred between wards/units within the hospital and where the risk to the patient may change due to the change in environment. Mr. BURKE was such a risk from falling whilst on the ward and therefore arrangements were required to be put in place to manage this risk, informed by a risk assessment. He had been admitted to Ipswich Hospital on 26th January 2023 following an unimpressed fall at rehabilitation centre where he had been discharged to from Ipswich Hospital the previous day; 25th January 2023. Mr. BURKE was moved to a new ward on the 30th January 2023 following his admission, assessment and initial treatment. He was not risk assessed when transferred to the ward and the outstanding task to carry out the risk assessment had not been completed by the end of the shift during which he had been transferred onto the ward. This requirement was not handed over to the on-coming shift and a falls risk assessment had not been completed at the time Mr. BURKE sustained a fall on the ward. I am concerned that Ipswich Hospital has inadequate arrangements in place to both highlight circumstances where the requirement for risk assessments have not been completed and in the arrangements for the handover of tasks (particularly falls assessments) between shifts. I am further concerned that the failure to have adequate arrangements in place to address this raises a risk of future deaths which I am under a duty to bring to your attention. ”
Source location
Michael John BURKE · 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
Inadequate arrangements for highlighting incomplete risk assessments
Wider context from the report
“The Court heard evidence that risk assessments were to be carried out regularly on patients in relation to their falls risk. This is particularly important in circumstances where a patient was being transferred between wards/units within the hospital and where the risk to the patient may change due to the change in environment. Mr. BURKE was such a risk from falling whilst on the ward and therefore arrangements were required to be put in place to manage this risk, informed by a risk assessment. He had been admitted to Ipswich Hospital on 26th January 2023 following an unimpressed fall at rehabilitation centre where he had been discharged to from Ipswich Hospital the previous day; 25th January 2023. Mr. BURKE was moved to a new ward on the 30th January 2023 following his admission, assessment and initial treatment. He was not risk assessed when transferred to the ward and the outstanding task to carry out the risk assessment had not been completed by the end of the shift during which he had been transferred onto the ward. This requirement was not handed over to the on-coming shift and a falls risk assessment had not been completed at the time Mr. BURKE sustained a fall on the ward. I am concerned that Ipswich Hospital has inadequate arrangements in place to both highlight circumstances where the requirement for risk assessments have not been completed and in the arrangements for the handover of tasks (particularly falls assessments) between shifts. I am further concerned that the failure to have adequate arrangements in place to address this raises a risk of future deaths which I am under a duty to bring to your attention. ”
Source location
Michael John BURKE · 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
Apply a six-hour timeframe for completing falls risk assessments after admission or ward transfer.

Verbatim wording from the response
“For this reason East Suffolk and North Essex NHS Foundation Trust sets a 6 hour assessment timeframe, from admission to hospital or change of ward, for the assessment to be carried out, to make patients as safe as can be.”

Source location
Response from East Suffolk and North Essex NHS Foundation Trust
Page 2 · response
Published 7 June 2024
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
Update the Falls Prevention Policy to require moving-and-handling assessments and Falls Prevention Integrated Care Pathways within six hours of admission or ward transfer.

Verbatim wording from the response
“As part of the ongoing review process of our policies, the Trust has reviewed and updated their Falls Prevention Policy, which provides staff with guidance on the need to complete a moving and handling assessment and Falls Prevention Integrated Care Pathway within 6 hours of a decision to admit or transfer wards. This policy will be signed off at the Patient Safety Group on 18 June 2024.”

Source location
Response from East Suffolk and North Essex NHS Foundation Trust
Page 2 · response
Published 7 June 2024
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
Amend the Integrated Patient Record with an updated falls risk assessment proforma specifying the six-hour completion requirement.

Verbatim wording from the response
“The Trust has also carried out a review of the Integrated Patient Record, which forms an appendix to the Falls Prevention Policy, has been amended and now includes an updated Falls risk assessment proforma, which highlights the need for the assessment to be completed within the 6 hour time period of admission/change of ward.”

Source location
Response from East Suffolk and North Essex NHS Foundation Trust
Page 2 · response
Published 7 June 2024
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 falls documentation through weekly ward-manager checks and monthly Matron quality audits.

Verbatim wording from the response
“As part of the Trust’s accountability framework, patient notes are audited frequently to ensure that they are being completed correctly and to identify any issues with compliance in completing notes.”

Source location
Response from East Suffolk and North Essex NHS Foundation Trust
Page 2 · response
Published 7 June 2024
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
Transition patient record keeping to an electronic system across the Trust by 2025.

Verbatim wording from the response
“The Trust has recently signed a contract to transition their patient records system to an electronic system, meaning that by 2025, all ESNEFT patient record keeping will be done electronically.”

Source location
Response from East Suffolk and North Essex NHS Foundation Trust
Page 3 · response
Published 7 June 2024
Open published response
1 May2024
West Yorkshire Eastern
Concerns raised1
1. Failure to provide complete fall-prevention fencing and barriers at car park levels
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
  Procure and install additional physical barriers at identified upper-floor locations and throughout the car park.
  Stated by Leeds City CouncilStated in progress
AI-generated summary

Laura Gawthorpe · 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

Laura Gawthorpe, a voluntary patient at the Becklin Centre in Leeds, left on escorted leave on 13 September 2022 and deliberately fell from a car park, dying instantly from unsurvivable injuries. The report raised concern that fencing and barriers were only partially installed at the level from which she fell, leaving a parapet wall that could still easily be climbed over.

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 provide complete fall-prevention fencing and barriers at car park levels
Wider context from the report
“(1) The evidence of West Yorkshire Police was that, by the erection of extensive fencing and barriers, measures have been put in place on levels ████████ at the car park to make it harder for people to fall from those levels, whether deliberately or accidentally. (2) The erection of similar measures on level ████████ has been only partial. The point from where Mrs Gawthorpe fell was identified by correlating her location on the ground with the location on level ████████ where she had left her phone before her fall. At that location, the parapet wall could still easily be climbed over. ”
Source location
Laura Gawthorpe · 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
Procure and install additional physical barriers at identified upper-floor locations and throughout the car park.

Verbatim wording from the response
“Since receiving your report we have been working very closely with a range of partners, including The Samaritans, Leeds City Council Public Health, and internal colleagues including Leeds Building Services, (our internal building services team), health and safety, communications, and our design and architecture technical consultants at Norse Consulting Ltd. to deliver a range of new prevention measures in relation to suicide at ████████. As part of our action plan, we have now finalised a technical specification for additional physical barriers at the locations you have identified on the ████████ floor and throughout the car park. A significant part of the car park already has barriers which have been installed at various times since the car park was originally built.”

Source location
2024-0242 - Response from Leeds City Council
Page 2 · response
Published 14 May 2024
Open published response
17 Apr2024
Wiltshire and Swindon
Concerns raised1
1. Insufficient staffing and resources for falls mitigation on hospital wards
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 2
1. Action
  Develop and provide national falls-risk guidance and implementation toolkits for hospital patients at risk of falls.
  Stated by NHS EnglandStated completed
2. Action
  Publish the NHS Long Term Workforce Plan to increase, train, retain and reform the NHS workforce.
  Stated by NHS EnglandStated completed
Respondent positions 3
1. Position
  Existing national falls guidance and implementation toolkits are considered sufficient to support appropriate falls-risk assessment and interventions.
  Stated by NHS EnglandExisting arrangements considered sufficient
1. Position
  Local nurse leaders are responsible for calculating safe staffing levels, with NHS Trust boards reporting staffing levels to NHS England.
  Stated by NHS EnglandRedirects responsibility
2. Position
  Responsibility for responding to the report’s concerns rests with NHS England, so no duplicate response will be provided.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Margaret Avril Burman · 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

Margaret Avril Burman, who preferred to be known as Avril, died on 13 July 2021 after an unwitnessed fall at Salisbury District Hospital caused a head injury and intracranial bleed. The report raises concerns that falls risk assessments and enhanced care arrangements were inadequate, and that staffing shortages meant no Healthcare Assistant was available to monitor the ward bay. It also identifies a broader concern that elderly hospital patients remain at significant risk of traumatic and fatal falls because appropriate falls mitigation measures are unavailable.

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
Insufficient staffing and resources for falls mitigation on hospital wards
Wider context from the report
“As I have previously indicated in a Regulation 28 Report submitted to you (Raymond Eggleton dated 17th November 2023 which remains unanswered by you) (Department of Health) falls in the hospital environment do not happen, however, as of the view in Avril’s case that had there been an appropriate Healthcare Assistant present then Avril’s fall and death more likely than not would have been avoided. During the course of the Inquest, I heard evidence from the Hospital’s Falls Specialist, ████████ who indicated that whilst staffing issues have improved there remains a difficulty ensuring appropriate staffing especially when responding to the ever-changing needs on wards where they are occupied by people at risk of falls. She explained to me that in relation to 2 wards in particular, one of which included Spire Ward which is a general geriatric surgical ward and the other which is a trauma and orthopaedic ward, both of which can take approximately 30 patients, that having conducted her own analysis it is transpired that of those admitted onto both those wards that approximately 80% either had a history of falls or the reason for their admission related to a fall. Of those at risk of a fall where the enhanced care toolkit had been deployed, she told me that 70% of those at falls risk required and warranted 1 to 1 support. Generally, these wards have a nursing ratio of between 1 to 8 patients or sometimes 1 to 6 patients with appropriate Healthcare Assistant support. As you can see in relation to a ward of 30 patients, a situation starts to present itself where the majority of personnel on the ward are not providing nursing support but are providing 1 to 1 falls mitigation support, and there simply are not the resources available to provide such cover. As a consequence, where there is an identifiable falls risk, the situation arises and continues at the moment where those patients are not being appropriately safeguarded against the risk of falls on wards. Especially where patients have conditions such as Dementia and Alzheimer’s it can sometimes be the case that it only takes a relatively minor collapse to cause a significant head trauma that leads to death. The position is further compounded by the fact that I was told the hospital is confronted with the additional problem that it can have up to 70% of those patients on these 2 wards being in a condition where they are medically stabilised and fit to be discharged but due to lack of appropriate care in the community they are remaining on the wards. The longer they remain on the wards the greater the risk of falls especially if they are medically stabilised when in such circumstances, they are more likely to be mobile. I asked ████████ as to how she thought that improvements could be made and she indicated to me in her evidence that she was of the view that there should be national leadership and a standardised toolkit when assessing falls risks on hospital wards and that there should also be a greater degree of sharing of learning where methods of good practice have been adopted by other Trusts that could easily be adopted by Trusts where this is a challenge. As I indicated in Mr Eggleton’s Regulation 28 Report, the problem here is multifactorial but as it remains at the moment, I am concerned that the elderly on hospital wards are at significant risk of sustaining a traumatic and fatal injury by having a fall on a ward due to the unavailability of appropriate and necessary falls mitigation measures. The resolution of this problem is not about the amount of money or the increase in money that is injected into the National Health Service and my concern is that a more strategic approach is required. More money may well indeed be injected into the National Health Service but with inflation as it has been and with wage rises that have taken place in real terms the increase maybe small and the reality is that in real terms it may amount to a reduction in what can be purchased with that money. The commitment to provide 5000 extra “core” beds to deal with increasing demand is only going to add to the concern unless this issue is addressed. As I have stated in my last Regulation 28 Report dealing with this issue, the problem is multifactorial, but it is a solution in respect of which the government undoubtedly has a crucial and essential role to play. ”
Source location
Margaret Avril Burman · 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
Develop and provide national falls-risk guidance and implementation toolkits for hospital patients at risk of falls.

Verbatim wording from the response
“Your Report raises concerns over appropriate staffing falls mitigation measures on wards occupied by people at risk of falls, in particular patients with dementia or Alzheimer’s Disease, and that there should be ‘national leadership and a standardised toolkit when assessing falls risk on hospital wards’ and that there should also be a greater degree of sharing of learning.”

Source location
Response from NHS England
Page 1 · response
Published 29 April 2024
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
Publish the NHS Long Term Workforce Plan to increase, train, retain and reform the NHS workforce.

Verbatim wording from the response
“Regarding staffing levels, the headcount for registered nurses and support staff has increased over the last decade,² however difficulties do remain in ensuring appropriate levels of staffing, especially to cover wards where patients are at risk of falls. Local nurse leaders are responsible for calculating safe levels of staffing using the Safer Nursing Care Tool - Sheffield Group and Boards for NHS Trusts have been required to report on their staffing levels to NHS England on a six-monthly basis since 2014.”

Source location
Response from NHS England
Page 2 · response
Published 29 April 2024
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
Existing national falls guidance and implementation toolkits are considered sufficient to support appropriate falls-risk assessment and interventions.

Verbatim wording from the response
“National leadership has already developed national guidance based on evidence-based practice which include falls risk assessment and toolkits to support implementation of appropriate interventions. At the time of Margaret’s admission to hospital in 2021, there was existing guidance available to support best practice around patients at risk of falls.”

Source location
Response from NHS England
Page 1 · response
Published 29 April 2024
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
Local nurse leaders are responsible for calculating safe staffing levels, with NHS Trust boards reporting staffing levels to NHS England.

Verbatim wording from the response
“Regarding staffing levels, the headcount for registered nurses and support staff has increased over the last decade,² however difficulties do remain in ensuring appropriate levels of staffing, especially to cover wards where patients are at risk of falls. Local nurse leaders are responsible for calculating safe levels of staffing using the Safer Nursing Care Tool - Sheffield Group and Boards for NHS Trusts have been required to report on their staffing levels to NHS England on a six-monthly basis since 2014.”

Source location
Response from NHS England
Page 2 · response
Published 29 April 2024
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
Responsibility for responding to the report’s concerns rests with NHS England, so no duplicate response will be provided.

Verbatim wording from the response
“I am aware that that the National Medical Director is responding to your report on behalf of NHS England and as such I do not intend to duplicate the contents of his communication with you. However, I am assured that NHS England have reflected upon the concerns raised in your report in relation to Ms Burman’s care.”

Source location
Response from DHSC
Page 1 · response
Published 29 April 2024
Open published response
16 Apr2024
Norfolk
Concerns raised4
1. Failure to provide carer supervision for very high-risk residents in communal areas
2. Failure to prevent falls through timely intervention when very high-risk residents mobilise
3. Lack of consistent and clear fall-risk mitigation requirements in care plans and risk assessments
1. Failure of staff to understand required fall-risk mitigation measures
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 8
1. Action
  Review and introduce assistive technology in communal and bedroom areas to alert staff when residents attempt to mobilise independently.
  Stated by Norfolk Care HomesStated completed
2. Action
  Allocate care staff to communal areas and provide staffed garden access with radios for rapid communication.
  Stated by Norfolk Care HomesStated completed
3. Action
  Introduce a Falls Champion role and competency checks to provide ongoing falls-prevention coaching and verify staff knowledge.
  Stated by Norfolk Care HomesStated completed
1. Action
  Review and update falls-related policies, procedures and auditing processes to identify inconsistencies and improve staff guidance.
  Stated by Norfolk Care HomesStated in progress
2. Action
  Revise care plans and risk assessments to provide person-focused, consistent falls-risk management guidance.
  Stated by Norfolk Care HomesStated completed
3. Action
  Implement monthly care-plan and risk-assessment audits covering at least 10% of the home.
  Stated by Norfolk Care HomesStated completed
4. Action
  Develop and extend falls-awareness training, including additional content in Moving and Handling and Safeguarding training.
  Stated by Norfolk Care HomesStated in progress
5. Action
  Share resident risk-overview information at handovers and maintain corresponding falls-risk information in the electronic care-plan system.
  Stated by Norfolk Care HomesStated in progress
Respondent positions 1
1. Position
  Internal auditing evidence assures that staff allocation effectively meets individual needs and supports the CQC report’s accuracy.
  Stated by Norfolk Care HomesExisting arrangements considered sufficient
AI-generated summary

Edith Jane ALDEN · 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

Edith Jane Alden, a resident assessed at very high risk of falls, left a communal area unnoticed and unsupervised on 13 September 2021, fell in the garden and suffered severe head injuries. She died on 25 September 2021. Concerns included unclear and inconsistent care plans and risk assessments, insufficient supervision and staffing, and the use of unlocked communal-area access for residents at very high risk of 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
Failure to provide carer supervision for very high-risk residents in communal areas
Wider context from the report
“3. Residents deemed at very high risk of falls were, and still are, allowed in communal areas with no carer present. ”
Source location
Edith Jane ALDEN · 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 prevent falls through timely intervention when very high-risk residents mobilise
Wider context from the report
“6. Residents deemed as at very high risk of falls were, and still are, in their bedrooms with a call bell and no other means to alert staff if they get out of bed and mobilise, this includes leaving their room and entering corridor areas. I am concerned this will lead to carers responding to a fallen resident, rather than preventing the fall. ”
Source location
Edith Jane ALDEN · 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
Lack of consistent and clear fall-risk mitigation requirements in care plans and risk assessments
Wider context from the report
“1. Care Plans and Risk Assessments were not consistent and clear as to what steps were required to mitigate the risks of Mrs Alden falling. ”
Source location
Edith Jane ALDEN · 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 of staff to understand required fall-risk mitigation measures
Wider context from the report
“2. Staff were unclear in evidence as to what was required in respect of Mrs Alden to mitigate the risks of her falling. ”
Source location
Edith Jane ALDEN · 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
Review and introduce assistive technology in communal and bedroom areas to alert staff when residents attempt to mobilise independently.

Verbatim wording from the response
“Assistive technology review of all equipment currently in use, additional equipment considered and introduced where appropriate. Equipment is reviewed following any changes to an individual’s physical, mental or emotional health. This is evidenced within assessments linked to the relevant change and within weekly clinical meetings. Management, senior staff are responsible for making these changes.”

Source location
2024-0196 Response from The Limes Care Home
Page 5 · response
Published 29 April 2024
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
Allocate care staff to communal areas and provide staffed garden access with radios for rapid communication.

Verbatim wording from the response
“Care staff are allocated to communal areas of the home to provide relevant help and support for any residents within these areas.”

Source location
2024-0196 Response from The Limes Care Home
Page 8 · response
Published 29 April 2024
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
Introduce a Falls Champion role and competency checks to provide ongoing falls-prevention coaching and verify staff knowledge.

Verbatim wording from the response
“Training We have reviewed the training we have in place to support staff. We have introduced a ‘Falls Champion’ role to provide continuous drive and improvements to our working practices. This is an active member of the staff team providing support, guidance and coaching around falls prevention. Knowledge and understanding checks through competency assessment and sign off following completion of this for each staff member. Our in house trainer has completed a falls, train the trainer programme, date 21st May 2024 this will also support ongoing improvements for both the training package being provided and the Falls Champion role. We will continue to develop and adapt our training with further awareness sessions being offered to friends, families and advocates etc.”

Source location
2024-0196 Response from The Limes Care Home
Page 3 · response
Published 29 April 2024
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
Review and update falls-related policies, procedures and auditing processes to identify inconsistencies and improve staff guidance.

Verbatim wording from the response
“Policies and procedure reviews Policies and procedures are continuously reviewed as part of our development as a company. Special emphasis has been given to any of our policies linked to falls, including environmental factors, individual risks, actions to be taken to improve staff guidance around understanding and interventions required to mitigate risks where possible.”

Source location
2024-0196 Response from The Limes Care Home
Page 3 · response
Published 29 April 2024
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
Revise care plans and risk assessments to provide person-focused, consistent falls-risk management guidance.

Verbatim wording from the response
“Care plans and risk assessments were fully reviewed and revised. Working with an external consultancy for guidance and advice we changed the structure and wording of our care plans to better reflect a person focused approach with a higher emphasise of risk management embedded within these documents.”

Source location
2024-0196 Response from The Limes Care Home
Page 4 · response
Published 29 April 2024
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
Implement monthly care-plan and risk-assessment audits covering at least 10% of the home.

Verbatim wording from the response
“Auditing care plans and risk assessments continue to be reviewed on a monthly basis as a minimum or when there is a significant change. Care plan audits have been completed with regional management support, and is now set as 10% of the home each month, being completed by the management team. This includes all aspects of the care plan including risk assessments, Mental Capacity assessments, front page, planned care, photo etc.”

Source location
2024-0196 Response from The Limes Care Home
Page 5 · response
Published 29 April 2024
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
Develop and extend falls-awareness training, including additional content in Moving and Handling and Safeguarding training.

Verbatim wording from the response
“Falls awareness training is being developed further, our trainer has completed a falls train the trainer session on 21st May 2024. Following this a full review of our current training linked to falls will be completed and additional details added to both the Moving and Handling training and Safeguarding training.”

Source location
2024-0196 Response from The Limes Care Home
Page 7 · response
Published 29 April 2024
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
Share resident risk-overview information at handovers and maintain corresponding falls-risk information in the electronic care-plan system.

Verbatim wording from the response
“Risk management risk overview sheets within the home shared at Handover meetings to highlight the risks associated with residents to all staff, to build on knowledge and understanding. Risks to be aware of on Person Centred Software (electronic care plan system used) checked and updated if required, again to support staff knowledge and understanding. Pre-admission assessments of falls risk have been introduced to identify and mitigate risks prior to admission. Falls risk analysis completed with the management team for the whole home, to drive further improvements and identify and mitigate risks where possible. Falls analysis is completed monthly for the whole home, this is managed as and when falls occur with weekly clinical meetings and weekly accident/incident sign offs by management.”

Source location
2024-0196 Response from The Limes Care Home
Page 5 · response
Published 29 April 2024
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
Internal auditing evidence assures that staff allocation effectively meets individual needs and supports the CQC report’s accuracy.

Verbatim wording from the response
“I’d respectfully draw Coroner’s attention to the fact that this is a report of the regulator and as such only the regulator can defend their report. We do happen to agree with CQC’s independent assessment dated 5th October 2022. The inspection is a ‘snapshot’ of our service. Our internal auditing processes provide evidence of our staff being allocated to areas throughout the service to effectively meet individual’s needs, which gives us the assurance that the remarks in the CQC report were accurate.”

Source location
2024-0196 Response from The Limes Care Home
Page 10 · response
Published 29 April 2024
Open published response
20 Mar2024
Gwent
Concerns raised1
1. Failure to investigate in-patient falls
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Operate a monthly Falls Review Panel to investigate injurious inpatient falls, identify learning, agree remedial actions and monitor fracture-related fall trends.
  Stated by Aneurin Bevan University LHBStated completed
2. Action
  Report inpatient falls through RLDatix and investigate falls causing fractures, with escalation through serious-incident and Duty of Candour processes where moderate or greater harm occurs.
  Stated by Aneurin Bevan University LHBStated completed
3. Action
  Strengthen the Serious Incident process by appointing investigating officers before initial meetings, providing investigation training, and applying enhanced governance and approval of reports and action plans.
  Stated by Aneurin Bevan University LHBStated completed
1. Action
  Use standardised Serious Incident agendas to define investigation scope, capture robust terms of reference, involve families from the outset and prompt reporting to external agencies.
  Stated by Aneurin Bevan University LHBStated completed
AI-generated summary

Neil Francis Edwards · 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

Neil Francis Edwards was admitted to hospital in respiratory failure, was at high risk of falling, and required 1:1 observation. He suffered four falls, including an unobserved fall on 01/05/2023 that caused a hip fracture; after surgery, he suffered a gastrointestinal haemorrhage and died. The principal concerns were that the falls, including the fall contributing to his death, were not investigated and that this left insufficient reassurance about preventing similar deaths.

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 investigate in-patient falls
Wider context from the report
“The inquest was advised that a Falls Panel had been convened to determine, in part, whether action could have been taken to prevent a fall which had occurred on 23/04/23. I received no evidence that there had been any investigation into the other falls including, importantly, the fall on 01/05/23 that contributed to Mr Edwards’ death. The court regularly hears that investigations into the circumstances of in-patient falls is central to minimising the risk going forward. It is of concern that no such investigation was undertaken at this time. Additionally, as there was no investigation, the court was not reassured as to how deaths in similar circumstances might be prevented in the future. ”
Source location
Neil Francis Edwards · 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
Operate a monthly Falls Review Panel to investigate injurious inpatient falls, identify learning, agree remedial actions and monitor fracture-related fall trends.

Verbatim wording from the response
“The Health Board has a Falls Policy in place for Hospital Adult inpatients. The Falls Policy must be implemented at all levels within the organisation to ensure a safe and consistent approach is adopted. The aim is to reduce avoidable, injurious falls whilst ensuring appropriate management of patients who experience a fall, to include collaboration with intermediate care and the frailty programme.”

Source location
Response from Aneurin Bevan University Health Board
Page 1 · response
Published 21 March 2024
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
Report inpatient falls through RLDatix and investigate falls causing fractures, with escalation through serious-incident and Duty of Candour processes where moderate or greater harm occurs.

Verbatim wording from the response
“Falls are reported via the Health Board’s incident reporting procedures, namely by completing an incident report via our electronic ‘RL Datix Incident’ reporting system. These reports are circulated to relevant staff and senior managers for review and action. Where any concerns are identified, consideration will then be given to the form and type of post fall investigation required. For cases identified where moderate harm or above, these will be managed in line with the Health Board’s”

Source location
Response from Aneurin Bevan University Health Board
Page 1 · response
Published 21 March 2024
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
Strengthen the Serious Incident process by appointing investigating officers before initial meetings, providing investigation training, and applying enhanced governance and approval of reports and action plans.

Verbatim wording from the response
“The Health Board’s Serious Incident Process has been reviewed to improve the scrutiny of incidents. Serious Incident meetings are considered mandatory and investigating officers are now appointed in advance of the first meeting to ensure the investigating officer can be present and engaged from the outset. The Health Board has been delivering Investigating officer training since September 2020 which includes SIs and complaints. The workshops are half day workshops based and provide Investigating Officers with a range of methodologies to use in their investigations.”

Source location
Response from Aneurin Bevan University Health Board
Page 3 · response
Published 21 March 2024
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
Use standardised Serious Incident agendas to define investigation scope, capture robust terms of reference, involve families from the outset and prompt reporting to external agencies.

Verbatim wording from the response
“Improved and standardised agendas have been introduced as part of the SI process to ensure that the scope of investigation and robust terms of reference are captured and referred back to at the end of the process and this will include the involvement of patient families and any concerns they may have, from the outset. The standardised agenda includes a prompt to ensure reporting to external Agencies such as NHS Executive and the HSE.”

Source location
Response from Aneurin Bevan University Health Board
Page 3 · response
Published 21 March 2024
Open published response
19 Jan2024
Suffolk
Concerns raised1
1. Failure to protect mobility scooter users from falls at unbarriered promenade edges
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Complete new and updated risk assessments for Felixstowe Promenade, including consideration of risks to mobility scooter users.
  Stated by East Suffolk CouncilStated completed
2. Action
  Commission a full disability access audit of the promenade and surrounding area from a Centre for Accessible Environments-accredited assessor.
  Stated by East Suffolk CouncilStated planned
3. Action
  Monitor beach levels at promenade road entrances and ramps for 12 months to inform further safety measures.
  Stated by East Suffolk CouncilStated planned
1. Action
  Renew existing hazard line markings along the promenade.
  Stated by East Suffolk CouncilStated planned
2. Action
  Investigate the effectiveness and practicality of seasonal or more frequent releveling of beach sand and shingle.
  Stated by East Suffolk CouncilStated planned
3. Action
  Install signage at locations where beach levels fluctuate and create a fall risk.
  Stated by East Suffolk CouncilStated planned
4. Action
  Continue monitoring the structural integrity of existing barriers and maintain them.
  Stated by East Suffolk CouncilStated completed
Respondent positions 2
1. Position
  Preventing mobility scooter users from falling asleep is largely outside the Council’s control, limiting further responsive safety work.
  Stated by East Suffolk CouncilUnable to act
1. Position
  Mobility scooter leasing companies, medical professionals, families and individuals should identify and address risks of falling asleep while using mobility scooters.
  Stated by East Suffolk CouncilRedirects responsibility
AI-generated summary

John Thomas GRAY · 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

John Thomas Gray died at Ipswich Hospital on 13 July 2022 after falling from the promenade at Felixstowe beach while asleep on his mobility scooter. He suffered multiple rib fractures leading to respiratory failure, and the inquest concluded that his death was accidental. The principal concern was that, where there was no barrier, existing signage and markings would not warn a person asleep on a mobility scooter about the risk of falling, potentially leading to future loss of life, particularly where the drop was unusually high.

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 protect mobility scooter users from falls at unbarriered promenade edges
Wider context from the report
“Evidence was also heard from a mobility scooter supplier and engineer, who explained that falling asleep on a mobility scooter was not uncommon, and happened more frequently than the general public might think. The supplier explained that this often led to accidents, leading to damage to the mobility scooters, which required repair. I am therefore concerned that falls from the promenade onto the beach, in areas where there is no barrier, would occur again in similar circumstances, as the current signage and markings provide no warning to an individual asleep on their mobility scooter. If this were to occur (as in this case) in an area where the height of drop from the edge of the promenade to the sand was greater than normally expected, I am concerned this would lead to future loss of life. ”
Source location
John Thomas GRAY · 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
Complete new and updated risk assessments for Felixstowe Promenade, including consideration of risks to mobility scooter users.

Verbatim wording from the response
“In light of the incident, and prior to the coroner’s conclusion being published, East Suffolk Council reviewed its risk assessments to ensure risks relating to all users, including those with mobility scooters, were considered. The result of those risk assessments forms the basis of the response below.”

Source location
Response from East Suffolk Council
Page 1 · response
Published 25 January 2024
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
Commission a full disability access audit of the promenade and surrounding area from a Centre for Accessible Environments-accredited assessor.

Verbatim wording from the response
“• Commission a full disability Access Audit of the promenade and its environs by a Centre for Accessible Environments (CAE) accredited assessor.”

Source location
Response from East Suffolk Council
Page 2 · response
Published 25 January 2024
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
Monitor beach levels at promenade road entrances and ramps for 12 months to inform further safety measures.

Verbatim wording from the response
“• Where required install guardrails (possibly removable) or other physical measures, such as corduroy paving, along full length of promenade edge or at particular higher risk points, such as entrance points/ramps off the road and locations where falls are onto rocks or hard surfaces (all subject to 12 months monitoring of beach levels and full disability Access Audit).”

Source location
Response from East Suffolk Council
Page 2 · response
Published 25 January 2024
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
Renew existing hazard line markings along the promenade.

Verbatim wording from the response
“• Renew existing hazard line markings”

Source location
Response from East Suffolk Council
Page 2 · response
Published 25 January 2024
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
Investigate the effectiveness and practicality of seasonal or more frequent releveling of beach sand and shingle.

Verbatim wording from the response
“• Investigate the effectiveness and practicality of seasonal (or more frequent releveling of sand and shingle).”

Source location
Response from East Suffolk Council
Page 2 · response
Published 25 January 2024
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
Install signage at locations where beach levels fluctuate and create a fall risk.

Verbatim wording from the response
“• Install signage where there is a risk of fluctuating beach levels.”

Source location
Response from East Suffolk Council
Page 2 · response
Published 25 January 2024
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
Continue monitoring the structural integrity of existing barriers and maintain them.

Verbatim wording from the response
“• Continue to monitor the structural integrity of the existing barriers and to maintain them.”

Source location
Response from East Suffolk Council
Page 2 · response
Published 25 January 2024
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
Preventing mobility scooter users from falling asleep is largely outside the Council’s control, limiting further responsive safety work.

Verbatim wording from the response
“We would add that there have been no similar accidents that we are aware of on any land within East Suffolk Council’s ownership. Therefore, the mitigations that we consider need to be proportionate to the risk presented. The Council’s view is that this is largely outside of our control. We would urge mobility scooter leasing companies to monitor distribution in cases such as this where an individual has a history of falling asleep due to medication and encourage medical professionals, family members and individuals themselves to recognise the risk that falling asleep on a mobility scooter presents in any circumstances and where this is identified, consider appropriate actions.”

Source location
Response from East Suffolk Council
Page 2 · response
Published 25 January 2024
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
Mobility scooter leasing companies, medical professionals, families and individuals should identify and address risks of falling asleep while using mobility scooters.

Verbatim wording from the response
“We would add that there have been no similar accidents that we are aware of on any land within East Suffolk Council’s ownership. Therefore, the mitigations that we consider need to be proportionate to the risk presented. The Council’s view is that this is largely outside of our control. We would urge mobility scooter leasing companies to monitor distribution in cases such as this where an individual has a history of falling asleep due to medication and encourage medical professionals, family members and individuals themselves to recognise the risk that falling asleep on a mobility scooter presents in any circumstances and where this is identified, consider appropriate actions.”

Source location
Response from East Suffolk Council
Page 2 · response
Published 25 January 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to document falls prevention measures following falls risk assessments

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

Concerns raised1

Failure to prevent predictable and avoidable falls

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

Concerns raised1

Failure to complete falls assessments before routinely erecting bed rails

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

Concerns raised1

Failure to conduct falls risk assessments on admission

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

Concerns raised2

Inadequate handover arrangements for outstanding falls assessments between shifts

Inadequate arrangements for highlighting incomplete risk assessments

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

Concerns raised1

Failure to provide complete fall-prevention fencing and barriers at car park levels

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

Concerns raised1

Insufficient staffing and resources for falls mitigation on hospital wards

Actions described in response 3

Respondent positions 1

Actions described in response 5

Actions described in response 4

Actions described in response 5

Actions described in response 1