Recurring concern

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

First to latest report 26 Oct 2015 — 10 Feb 2021

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
2

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.

What is 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 and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Black Country

    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

  2. Inner North London

    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

  3. Birmingham and Solihull

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026