Recurring concern

Failure to promptly escalate patient falls to responsible senior clinicians and managers

Get email alerts

Request correction

First reported 26 Oct 2015•Latest report 10 Feb 2021

Definition

What this concern includes

Includes failures to recognise, communicate, document or escalate a patient fall promptly to the responsible senior clinical or management function when senior review or oversight is needed after the fall.

Not included

Excludes falls-prevention, observation, treatment, investigation or post-fall care failures where escalation to responsible senior clinicians or managers is not the deficient control.
Excludes generic delays in notifying families, next of kin or other non-responsible recipients after a fall.
Excludes generic upward-escalation failures unrelated to patient falls.
Excludes delays occurring after the responsible senior clinician or manager has been reliably notified, including failures in the subsequent review or care decision.

Reports: 3
Individual concerns: 3
Date range: 2015–2021
Stated actions: 2

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.

Care Quality Commission1

Castlehill Specialist Care Centre1

Royal London Hospital1

Sunrise Care Home1

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.

10 Feb2021
Black Country
Concerns raised1
1. Delays in notifying senior management after a fall
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
  Stated by Care Quality CommissionStated completed
Respondent positions 1
1. 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 act
AI-generated summary

Eric Harold Bird · 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

Eric Harold Bird, a 91-year-old man with dementia and assessed as being at high risk of falls, suffered seven falls during a four-week period in a specialist care centre. After a fall on 21/11/20, he sustained a subdural haematoma and died in hospital on 30/11/20. The principal concerns included failures to follow procedures after head injuries, delays in contacting emergency services and gaining ambulance access, and inadequate updating and review of his falls risk documentation and care plan.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in notifying senior management after a fall
Wider context from the report
“8. I heard evidence that after the fall on 21/11/20 whereby Mr Bird was taken to hospital, that senior management who were off site were not contacted for over 2 hours after Mr Bird fell; ”
Source location
Eric Harold Bird · 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
Conduct management reviews and assess available evidence about the provider’s falls-management concerns.

Verbatim wording from the response
“The matters of concern which arose from the preventing future deaths report have prompted the CQC to take action. In direct response, we held a management review meeting on 17 February 2021. Following the management review meeting, we reviewed the evidence we held about Castlehill Specialist Care Centre, the information held following the specific incident review related to Mr Bird’s death and information following the inspection completed in January 2021.”

Source location
2021-0122-Response-from-Care-Quality-Commission-Redacted
Page 2 · response
Published 4 May 2021
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
CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.

Verbatim wording from the response
“• As a result of these findings, CQC held a management review meeting on 18 March 2021 to discuss the findings under our specific incident guidance. In order to open a formal criminal investigation, we have to be able to evidence a Registered Person (either a Registered Provider or Registered Manager) failed to provide safe care and treatment to Mr Bird in relation to this incident and can prove beyond reasonable doubt this incident was avoidable. We did not feel that this threshold was met and therefore will not progress the case.”

Source location
2021-0122-Response-from-Care-Quality-Commission-Redacted
Page 3 · response
Published 4 May 2021
Open published response
26 Jul2016
Inner North London
Concerns raised1
1. Delay in escalating falls to the responsible consultant
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Deliver multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.
  Stated by Barts Health NHS TrustStated completed
AI-generated summary

Margaret Emily TUCK · 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 Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

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
Delay in escalating falls to the responsible consultant
Wider context from the report
“5. The consultant in charge of Mrs Tuck’s care did not learn of the 15 October fall until 17 October. It seems that the junior doctors on her ward did not bring this to her attention. Mrs Tuck’s nephew, however, was gravely concerned to find his auntie unable to communicate, and brought this to the attention of the consultant. The consultant asked him “What do you want me to do, scan her brain?” and he replied “I think that would be a very good idea”. Hence a CT scan was conducted on the afternoon of 17 October. ”
Source location
Margaret Emily TUCK · Prevention of Future Deaths report
Page 3 · 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
Deliver multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.

Verbatim wording from the response
“3. Our Nurse Educator has been instrumental in setting up and delivering a new multi-disciplinary training programme around important issues, that includes falls prevention awareness and post falls care. As part of the Band 7 role regular assessment during the shift of care planned and delivered, is undertaken. All of our medical staff, including FY1’s, are invited to participate. Falls prevention and awareness is also included in the FY1 mandatory education programme. With the increased presence of Band 6 and 7 nurses on each shift all the clinical staff now have a first contact who they can handover important issues to, even when the named nurse is not on the ward. There are now four multidisciplinary board / handover meetings per 24-hours and these are focussed around patient safety and handover.”

Source location
2016-0273-Response-by-Barths-Health-NHS-Trust
Page 3 · response
Published 26 July 2016
Open published response
26 Oct2015
Birmingham and Solihull
Concerns raised1
1. Failure to escalate falls to appropriate senior staff
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Allan Richard Beasley · 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

Allan Richard Beasley, who had vascular dementia, was admitted to a care home after he could no longer manage at home and experienced multiple falls. Following a further fall, he was diagnosed with cervical spine fractures, developed a chest infection, deteriorated and died. Concerns included inadequate falls-risk assessment, failures to record and escalate falls, inaccurate observation records, and incomplete monitoring and review.

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 escalate falls to appropriate senior staff
Wider context from the report
“(1) Staff were unaware of the Home’s Falls Prevention Policy. This meant staff failed to correctly record falls and escalate to appropriate senior staff. ”
Source location
Allan Richard Beasley · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in notifying senior management after a fall

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

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

Concerns raised1

Delay in escalating falls to the responsible consultant

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

Failure to escalate falls to appropriate senior staff

Actions described in response 1

Respondent positions 1

Actions described in response 1