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.
Mid Kent and Medway
Concerns raised1
Chronic shortages of falls alarm equipment for patients assessed as requiring it
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Purchase additional falls alarms, bed sensor pads and chair sensor pads to increase available equipment.
Stated by Medway NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 April 2021.
Action
Implement ward-level stocktaking, local stock monitoring and daily checks alongside the centrally held falls-equipment reserve.
Stated by Medway NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 April 2021.
Action
Identify budget and establish RFID tagging, logging and tracking for falls equipment.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Action
Disseminate and require compliance with the falls-equipment procurement and non-availability escalation procedure.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Action
Maintain up-to-date falls-equipment training for staff working predominantly nights.
Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2021.
Action
Remind appropriate staff to report and escalate falls-equipment shortages promptly.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Action
Require Clinical Engineering to notify the dedicated falls team of shortages and provide twice-yearly stock reports and annual stocktakes.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Action
Maintain 10 dedicated, tracked falls alarms in the Emergency Cupboard at all times.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Manchester North
Concerns raised1
Failure to provide accessible call alarms for residents at moderate or high risk of falls
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
Direct staff to attach call bells to people rather than walls, including enabling at-risk independent people to wear them.
Stated by RochCare (UK) LtdStated completedThe respondent said that this action was complete when they made their response on 27 May 2021.
Sefton, St. Helens and Knowsley
Concerns raised4
Failure to report falls-related matters to regulatory bodies
Delayed staff supervision and discussion of falls prevention
Failure to commence a timely investigation of falls-related matters
Failure to apply falls risk assessment and prevention procedures
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Reinforce falls procedures through staff supervision and deliver falls-awareness presentations across the care home, district and national services.
Stated by Anchor Hanover GroupStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
Action
Review the internal coroner process and introduce formal safeguarding-team triage to monitor trends and support risk assessment.
Stated by Anchor Hanover GroupStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
Action
Maintain and apply comprehensive falls-management procedures covering risk assessment, prevention plans, post-fall observations, audits, response guidance, documentation and staff training.
Stated by Anchor Hanover GroupStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
Action
Introduce sensor-mat guidance and mandatory sensor-check documentation through the updated Call Systems and Assistive Technology policy.
Stated by Anchor Hanover GroupStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
Action
Implement falls-monitoring workbooks requiring individual tracking, physical home-manager audits and monthly national reporting to strengthen oversight and intervention.
Stated by Anchor Hanover GroupStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2021.
Action
Develop and nationally roll out a simplified falls-response flowchart.
Stated by Anchor Hanover GroupStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Reporting and record-keeping shortcomings were deliberate, isolated to the care home, and not representative of organisational operations.
Stated by Anchor Hanover GroupDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing falls-risk, risk-management and governance processes are considered robust, suitable and effective across all registered locations.
Stated by Anchor Hanover GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Birmingham and Solihull
Concerns raised2
Failure to formally review falls risk assessments and care policies after a resident death
Failure to update residents' falls risk assessments
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
Conduct internal investigations of all falls, attach action plans, and report falls and incidents weekly to the Nominated Individual.
Stated by Cole Valley Nursing HomeStated plannedThe respondent said that this action was planned when they made their response on 30 March 2021.
Action
Display a named nurse list and have the manager and deputy manager monitor and plan evaluations and risk assessments when nurses are unavailable.
Stated by Cole Valley Nursing HomeStated plannedThe respondent said that this action was planned when they made their response on 30 March 2021.
Plymouth, Torbay and South Devon
Concerns raised1
Lack of care and nursing staff awareness of the risks of medical complications following falls and long lies
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
Provide first aid training to all staff responsible for shifts, covering emergency response, falls, choking, bleeding, CPR and related care.
Stated by Hart Care LimitedStated completedThe respondent said that this action was complete when they made their response on 30 March 2021.
Gwent
Concerns raised2
Failure to complete falls risk assessments and documentation
Omissions in the falls risk assessment process
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Gwent
Concerns raised2
Failure to provide required enhanced supervision for high-falls-risk patients
Failure to provide multidisciplinary falls prevention and management
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.7
Action
Increase the substantive Health Care Support Worker workforce to support enhanced care and continuity.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 30 March 2021.
Action
Revise the Falls Policy for Hospital Adult Inpatients to define multidisciplinary assessment, care planning and professional responsibilities.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 30 March 2021.
Action
Obtain ratification and publish the revised Falls Policy for Hospital Adult Inpatients.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 30 March 2021.
Action
Develop and implement a multidisciplinary falls-policy implementation plan, including ward-based and online staff training.
Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 30 March 2021.
Action
Evaluate falls training and monitor compliance, including multidisciplinary participation.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 30 March 2021.
Action
Introduce ward-level Falls Prevention Collaboratives using quality-improvement methods, thematic reviews and multidisciplinary participation.
Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 30 March 2021.
Action
Review and monitor completion of falls-prevention actions and evidence of multidisciplinary care-plan participation and ownership.
Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 30 March 2021.
Black Country
Concerns raised4
Failure to complete required referral to the physiotherapy team
Failure to identify and address patterns of falls and increasing risk
Failure to update falls risk assessments and care plans after every fall
Failure to update falls risk assessments and care plans after every fall
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Hold weekly ward rounds with the GP and senior nursing team to discuss information and multidisciplinary referrals and make appropriate referrals.
Stated by Castlehill Specialist Care CentreStated completedThe respondent said that this action was complete when they made their response on 4 May 2021.
Action
Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 4 May 2021.
Action
Continue raising safeguarding alerts after falls.
Stated by Castlehill Specialist Care CentreStated completedThe respondent said that this action was complete when they made their response on 4 May 2021.
Action
Request one-to-one funding where appropriate to maintain resident safety during further assessments.
Stated by Castlehill Specialist Care CentreStated plannedThe respondent said that this action was planned when they made their response on 4 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.
Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Declined one-to-one funding can prevent maintaining enhanced supervision while further resident safety assessments are undertaken.
Stated by Castlehill Specialist Care CentreUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Norfolk
Concerns raised1
Failure to provide appropriate falls prevention for patients in cohorted hospital bays
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Complete review and adjustment of the NICE-compliant falls-risk assessment, Safety Sides assessment and associated policy.
Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 February 2021.
Action
Implement the revised falls-risk and Safety Sides assessment documents after final review and completion of related booklet reviews.
Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 February 2021.
Action
Develop an education package supporting revised falls assessments and recognition of multifactorial falls risks.
Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 February 2021.
Inner North London
Concerns raised2
Failure by staff to properly review Falls Assessment Tools
Failure to properly complete Falls Assessment Tools
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.1
Action
Validate Perfect Ward documentation-audit results through monthly senior-nurse review of submitted results and supporting documentation.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 January 2021.
Pin
Get email alerts
Request correction
Includes assessment, care planning, equipment, supervision, handover, referral, reporting, post-fall response and assurance explicitly dedicated to falls risk.
