Recurring concern

Incomplete consideration of relevant factors in falls risk assessments

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First reported 3 Mar 2015•Latest report 17 Nov 2023

Definition

What this concern includes

Includes failures in falls risk assessments to identify, obtain, consider, document or appropriately weight relevant factors affecting a person's likelihood or potential severity of a fall, including medication changes, clinical needs, attachments, mobility requirements, confusion and other patient-specific information.

Not included

Excludes the general prevention, supervision, equipment or response to falls where the falls risk-assessment process is not itself deficient.
Excludes failures to perform any falls assessment at all when the supported concern is solely omission of the assessment rather than incomplete consideration within the assessment; such assertions may belong to a broader falls-control concern.
Excludes generic risk-assessment deficiencies without a material falls-risk context.
Excludes failures to implement protective measures after a complete and accurate falls risk assessment unless the assessment itself was also incomplete or misleading.
Excludes generic medication, mental-health, documentation or training deficiencies that are not directly tied to incomplete consideration in a falls risk assessment.

Reports: 7
Individual concerns: 9
Date range: 2015–2023
Stated actions: 13

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.

Welsh Government2

Bolton Borough Council1

Brunswick Ward at Lindridge1

Cardiff & Vale University LHB1

County Durham and Darlington NHS Foundation Trust1

Department of Health and Social Care1

Great Western Hospital1

NHS Bolton Clinical Commissioning Group1

Office of the Chief Coroner1

Recipient name withheld1

Shannon Court Care Centre1

Sussex Partnership NHS Foundation Trust1

Swansea Bay University Local Health Board1

University Hospitals Birmingham NHS Foundation Trust1

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.

17 Nov2023
Wiltshire and Swindon
Concerns raised1
1. Failure to complete initial falls risk assessments using all available information
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
  Operate staffing governance and deployment processes using acuity data, enhanced-care assessments and three-times-daily staffing meetings.
  Stated by Great Western Hospitals NHS Foundation TrustStated completed
2. Action
  Review the enhanced-care policy, documentation and teaching to clarify assessment requirements and supervision levels.
  Stated by Great Western Hospitals NHS Foundation TrustStated in progress
3. Action
  Trial the enhanced-care and ‘Stay in the bay’ approach on three wards, with daily review of assessments, care gaps and education.
  Stated by Great Western Hospitals NHS Foundation TrustStated in progress
1. Action
  Develop a handover tool that records patients’ falls risks in greater detail.
  Stated by Great Western Hospitals NHS Foundation TrustStated in progress
2. Action
  Provide Acute Medical Unit training on multifactorial falls assessment, including risks, information sources and supervision levels.
  Stated by Great Western Hospitals NHS Foundation TrustStated planned
AI-generated summary

Raymond Lionel Eggleton · 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

Raymond Lionel Eggleton died in hospital on 25 January 2023 after falling on a medical unit, sustaining a fractured neck of femur and head injuries, and subsequently developing dysphagia, immobility, delirium and aspiration pneumonia. The principal concerns were that his falls risk assessment did not use all available information about his previous falls and postural hypotension, resulting in inadequate supervision, and that the ward lacked sufficient flexibility and resilience to respond dynamically to vulnerable patients’ enhanced care needs, particularly during night shifts.

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 initial falls risk assessments using all available information
Wider context from the report
“During the course of the Inquest, I also heard evidence from Sister Jones and in addition to the challenge of getting the staffing levels commensurate to the patients needs and safeguarding patients there does appear to be an issue that causes me a concern as regards the ability to dynamically respond to a need for enhanced supervision especially entering into night shifts. Sister Jones when questioned was open and extremely candid in her answer that at those times nursing staff could not always support those additional needs in the short term because of the challenge to get additional personal at short notice in circumstances where the nursing team were under pressure due to the complexities and demands of patient’s needs. There is in my view no flexibility and resilience within the system to dynamically adapt and respond to changing patients enhanced needs exacerbated by the fact that especially during the winter months those beds are mainly occupied by the elderly. It is easier during day shifts to respond but there clearly appears to be an issue especially going into night shifts. There were 2 issues here, firstly the initial falls risk assessment on LAMU which was not undertaken taking advantage of all available information which in my view led to an incorrect assessment of Ray’s supervision needs. His fall was observed by another member of the nursing staff and therefore my view is that only arm’s length supervision would have avoided the fall and that there were sufficient indicators on two occasions prior to the event occurring. The failure here in relation to the initial assessment was down to the volume of work and not in my view laziness or anything of that nature on the part of nursing staff. Flowing from the first issue a further issue relates to the resilience and the ability to respond dynamically with changing patients on the ward so as to ensure that vulnerable patients with a high degree of risk of falling, like Ray, are properly safeguarded. ”
Source location
Raymond Lionel Eggleton · 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
Operate staffing governance and deployment processes using acuity data, enhanced-care assessments and three-times-daily staffing meetings.

Verbatim wording from the response
“The Trust has robust safe staffing processes which are in line with national guidance and evidence based. This includes a 6 monthly safe staffing report to Trust Board which includes details of the Chief Nurses yearly establishment reviews with the ward managers. Nurse to patient ratios, benchmarking data, patient acuity, quality metrics and enhanced care data are reviewed as part of the Chief Nurse yearly establishment reviews.”

Source location
Response from Great Western Hospitals
Page 1 · response
Published 22 November 2023
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 the enhanced-care policy, documentation and teaching to clarify assessment requirements and supervision levels.

Verbatim wording from the response
“The Trust has had an enhanced care policy in place for several years. The Deputy Divisional Directors of Nursing are working with the Falls Team and undertaking a review of the current policy, paperwork and teaching. This work has an emphasis on the correct assessment and clear definitions of levels of supervision e.g. line of sight and within arm’s reach. This is supported by a ‘Stay in the bay’ approach when health care support workers are providing enhanced care. This mandates that before the designated staff leaves, this duty has to be handed over to another member of staff.”

Source location
Response from Great Western Hospitals
Page 2 · response
Published 22 November 2023
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 the enhanced-care and ‘Stay in the bay’ approach on three wards, with daily review of assessments, care gaps and education.

Verbatim wording from the response
“The Trust has had an enhanced care policy in place for several years. The Deputy Divisional Directors of Nursing are working with the Falls Team and undertaking a review of the current policy, paperwork and teaching. This work has an emphasis on the correct assessment and clear definitions of levels of supervision e.g. line of sight and within arm’s reach. This is supported by a ‘Stay in the bay’ approach when health care support workers are providing enhanced care. This mandates that before the designated staff leaves, this duty has to be handed over to another member of staff.”

Source location
Response from Great Western Hospitals
Page 2 · response
Published 22 November 2023
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 a handover tool that records patients’ falls risks in greater detail.

Verbatim wording from the response
“The other area of focus is to improve the handover process on the patient’s risk of falling and a new handover tool is being developed which will highlight the falls risk in more detail.”

Source location
Response from Great Western Hospitals
Page 3 · response
Published 22 November 2023
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
Provide Acute Medical Unit training on multifactorial falls assessment, including risks, information sources and supervision levels.

Verbatim wording from the response
“The Falls team will be providing additional training in the Acute Medical Unit on Multifactorial falls assessment, this training will include the essential components and sources of information required to support a personalised assessment, identifying key risks and level of supervision.”

Source location
Response from Great Western Hospitals
Page 3 · response
Published 22 November 2023
Open published response
19 May2023
Birmingham and Solihull
Concerns raised3
1. Failure of the falls risk assessment document to prompt consideration or documentation of attachments
2. Failure of documentation on other forms to prompt reconsideration of the falls risk assessment
3. Failure of the falls risk assessment document to prompt assessment of attachment relevance
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
  Review the falls risk assessment and identify required improvements to capture equipment-related mobility risks.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
2. Action
  Add a PICS falls-assessment dropdown for equipment such as drains and record the selected information in the Patient Handling Assessment Form.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Manual handling and falls assessments need not automatically feed into each other because staff are expected to consider them together with other records.
  Stated by University Hospitals Birmingham NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Norma Winifred BRUTON · 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

Norma Winifred BRUTON was admitted to hospital with a pneumothorax and other lung conditions, suffered an unwitnessed fall while walking to the bathroom, and sustained a fractured neck of femur. Her condition deteriorated after surgery and she died in hospital; concerns related to falls-risk assessments not prompting staff to consider or document attachments such as chest drains and intravenous infusions, or their relevance to falls risk.

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 of the falls risk assessment document to prompt consideration or documentation of attachments
Wider context from the report
“1. The Birmingham Heartlands Hospital falls risk assessment document does not prompt staff to consider or document the presence of attachments such as chest drains or intravenous infusions. 2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls. 3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment. ”
Source location
Norma Winifred BRUTON · Prevention of Future Deaths report
Page 1 · 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 documentation on other forms to prompt reconsideration of the falls risk assessment
Wider context from the report
“1. The Birmingham Heartlands Hospital falls risk assessment document does not prompt staff to consider or document the presence of attachments such as chest drains or intravenous infusions. 2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls. 3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment. ”
Source location
Norma Winifred BRUTON · Prevention of Future Deaths report
Page 1 · 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 the falls risk assessment document to prompt assessment of attachment relevance
Wider context from the report
“1. The Birmingham Heartlands Hospital falls risk assessment document does not prompt staff to consider or document the presence of attachments such as chest drains or intravenous infusions. 2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls. 3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment. ”
Source location
Norma Winifred BRUTON · 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
Review the falls risk assessment and identify required improvements to capture equipment-related mobility risks.

Verbatim wording from the response
“Updates to falls risk assessment document We have considered the concerns you have raised within your report to prevent future deaths and we are taking steps to add in a drop down menu, within the falls risk assessment, which will allow staff to select an appropriate option if a patient has any equipment, such as drains, in place. This will then also be recorded in the PHAF (Patient Handling Assessment Form) therefore attachments will be reflected in both risk assessments. This will further increase staff awareness of falls risk factors.”

Source location
Response from University Hospitals Birmingham NHS Foundation Trust
Page 2 · response
Published 19 May 2023
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
Add a PICS falls-assessment dropdown for equipment such as drains and record the selected information in the Patient Handling Assessment Form.

Verbatim wording from the response
“Updates to falls risk assessment document We have considered the concerns you have raised within your report to prevent future deaths and we are taking steps to add in a drop down menu, within the falls risk assessment, which will allow staff to select an appropriate option if a patient has any equipment, such as drains, in place. This will then also be recorded in the PHAF (Patient Handling Assessment Form) therefore attachments will be reflected in both risk assessments. This will further increase staff awareness of falls risk factors.”

Source location
Response from University Hospitals Birmingham NHS Foundation Trust
Page 2 · response
Published 19 May 2023
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
Manual handling and falls assessments need not automatically feed into each other because staff are expected to consider them together with other records.

Verbatim wording from the response
“The information recorded in the manual handling assessment has not been designed to automatically feed into the falls risk assessment as this was considered to be a duplication of the information in the patient record. The recommendation is that these assessments are looked at in combination not isolation.”

Source location
Response from University Hospitals Birmingham NHS Foundation Trust
Page 2 · response
Published 19 May 2023
Open published response
24 May2021
Manchester West
Concerns raised1
1. Failure to account for sedative medication changes in falls risk assessment
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

KENNETH SMITH · 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

Kenneth Smith, who had cognitive impairment and was at high risk of falls, died on 9 November 2020 after falling at a care home and developing acute-on-chronic subdural haematomas. The report raised concerns about reducing his supervision, failing to set a review date, inadequate escalation of care after further falls, and insufficient consideration of medication and mental-health factors in assessing his falls risk.

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 account for sedative medication changes in falls risk assessment
Wider context from the report
“After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020. Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered. The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury. Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all. Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020. The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns: 1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful. 2. The failure to consider and specify a review date; 3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review. 4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority; ”
Source location
KENNETH SMITH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Feb2017
Brighton and Hove
Concerns raised1
1. Failure to incorporate family information into falls risk assessment
This report raised 25 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

Derek LEE · 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

Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

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 incorporate family information into falls risk assessment
Wider context from the report
“(3) His Falls Risk Assessment was flawed in that it failed to take into account information from his wife and son as to how he was mobilising at home. Mobilisation in Mr Lee’s case should have been at the core of the Care Plan because he was suffering from Parkinson’s Disease, where if possible, it is important to maintain mobility. Brunswick Ward should know that. ”
Source location
Derek LEE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Dec2016
South Wales Central
Concerns raised1
1. Failure to integrate and respond to the whole picture of ongoing falls risk
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 2
1. Action
  Introduce National Patient Safety Agency falls risk assessments.
  Stated by Swansea Bay University Local Health BoardStated completed
2. Action
  Continue Falls Management Group scrutiny of training, individual falls reviews and performance data.
  Stated by Swansea Bay University Local Health BoardStated in progress
Respondent positions 1
1. Position
  Falls management is devolved to directly managed units, while the Falls Management Group retains scrutiny and performance-review functions.
  Stated by Swansea Bay University Local Health BoardRedirects responsibility
AI-generated summary

David Bassett COOPER · 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

David Bassett Cooper was admitted to hospital after a serious head injury caused by a fall in the community and sustained nine further falls while being transferred between wards. He died from a subdural haematoma caused by the final fall on 5 March 2016. The concerns included inadequate handovers about falls risk, incomplete nursing records, a failure to see the overall pattern of falls, and shortcomings in arranging additional one-to-one nursing care.

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 integrate and respond to the whole picture of ongoing falls risk
Wider context from the report
“3. The evidence revealed that there was a distinct lack of “joined up” thinking and a failure to see the “whole picture”. Mr Cooper’s risk of falling was as high when he was admitted in October 2015 as it was when he died in March 2016, but still he sustained 9 falls. ”
Source location
David Bassett COOPER · 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
Introduce National Patient Safety Agency falls risk assessments.

Verbatim wording from the response
“The Health Board established a Falls Management Group in September 2015. This was a task and finish group that reviewed policies and training requirements in relation to falls management. The Health Board introduced the National Patient Safety Agency’s Risk Assessments and I enclose the Health Board’s Falls Policy and other supporting information for your review. The Falls Management Group last met in December 2016 and devolved falls management to the Directly Managed Units to ensure clinical orientation and responsibility.”

Source location
2016-0459-Response-by-University-Health-Board
Page 1 · response
Published 12 February 2017
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 Falls Management Group scrutiny of training, individual falls reviews and performance data.

Verbatim wording from the response
“The Falls Management Group will continue to meet as a scrutiny panel to ensure that appropriate training and individual falls scrutiny is being undertaken along with continued review of performance data. ████████ Consultant Physician and Geriatrician, will be leading the Falls Management Group.”

Source location
2016-0459-Response-by-University-Health-Board
Page 1 · response
Published 12 February 2017
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
Falls management is devolved to directly managed units, while the Falls Management Group retains scrutiny and performance-review functions.

Verbatim wording from the response
“The Health Board established a Falls Management Group in September 2015. This was a task and finish group that reviewed policies and training requirements in relation to falls management. The Health Board introduced the National Patient Safety Agency’s Risk Assessments and I enclose the Health Board’s Falls Policy and other supporting information for your review. The Falls Management Group last met in December 2016 and devolved falls management to the Directly Managed Units to ensure clinical orientation and responsibility.”

Source location
2016-0459-Response-by-University-Health-Board
Page 1 · response
Published 12 February 2017
Open published response
7 Nov2016
South Wales Central
Concerns raised1
1. Failure to comprehensively assess and record falls risk and implement a clear care plan
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 4
1. Action
  Commence and regularly review falls care plans for all patients identified as at risk.
  Stated by Cardiff & Vale University LHBStated completed
2. Action
  Discuss falls risk assessment outcomes and 1:1 specialling requirements with families and carers, incorporating their views.
  Stated by Cardiff & Vale University LHBStated completed
3. Action
  Maintain behaviour charts to identify triggers for falls and wandering behaviour.
  Stated by Cardiff & Vale University LHBStated completed
1. Action
  Complete daily multidisciplinary Board Rounds providing a patient-centred holistic review.
  Stated by Cardiff & Vale University LHBStated completed
AI-generated summary

Maurice ISAACS · 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

Maurice ISAACS, who had dementia and other chronic health conditions, was admitted to hospital after deteriorating and suffered multiple falls. He fell from his bed on 12 June 2016, sustained a head injury and died two days later. Concerns included shortcomings in falls-risk assessment, care planning and supervision, as well as failures in carrying out and overseeing neurological observations after the final fall.

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 comprehensively assess and record falls risk and implement a clear care plan
Wider context from the report
“(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded. For example, no clear care plan was introduced until after the fourth fall. Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation. Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis. Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward. His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated. The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that, might have prevented so many falls. ”
Source location
Maurice ISAACS · 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
Commence and regularly review falls care plans for all patients identified as at risk.

Verbatim wording from the response
“The Medicine Clinical Board, in conjunction with all Directorates, have put in place the following key changes to identify how risk is assessed and the level of specialling that a patient requires to support a more holistic approach. When completing the falls risk assessment, all patients identified as at risk have a falls care plan commenced. This care plan is reviewed weekly, or more frequently as the patient’s health and requirements change. Since the tragic incident involving Mr I, the Clinical Board recognises the need for more robust discussion of the risk assessment outcome and the need for 1:1 specialling with families/carers. Families and carers are now actively encouraged to share their opinions if they feel 1:1 specialling is not appropriate for their relative or if they may respond poorly to this type of enhanced monitoring.”

Source location
2016-0411-Response-by-Uiniversity-Hospital-of-Wales
Page 2 · response
Published 9 February 2017
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 risk assessment outcomes and 1:1 specialling requirements with families and carers, incorporating their views.

Verbatim wording from the response
“The Medicine Clinical Board, in conjunction with all Directorates, have put in place the following key changes to identify how risk is assessed and the level of specialling that a patient requires to support a more holistic approach. When completing the falls risk assessment, all patients identified as at risk have a falls care plan commenced. This care plan is reviewed weekly, or more frequently as the patient’s health and requirements change. Since the tragic incident involving Mr I, the Clinical Board recognises the need for more robust discussion of the risk assessment outcome and the need for 1:1 specialling with families/carers. Families and carers are now actively encouraged to share their opinions if they feel 1:1 specialling is not appropriate for their relative or if they may respond poorly to this type of enhanced monitoring.”

Source location
2016-0411-Response-by-Uiniversity-Hospital-of-Wales
Page 2 · response
Published 9 February 2017
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
Maintain behaviour charts to identify triggers for falls and wandering behaviour.

Verbatim wording from the response
“All patients with known cognitive impairment have documentation completed by themselves or by a relative or carer in order to help healthcare staff learn about the patient as a person. We recognise that in the case of Mr I, regrettably, the ‘Reach Out To Me’ document had not been completed. All staff have been reminded of this and it will form part of regular documentation audits. Behaviour charts are maintained to identify any triggers for falls and wandering behaviour. Tools such as Intentional Rounding, which ensures that patients are reviewed every two hours in order to ensure that patients have a drink, are offered toileting in a timely manner are well embedded within all Directorates. Medication reviews are undertaken weekly by the medical team and Pharmacy colleagues to minimise medication interactions and use of sedative medication.”

Source location
2016-0411-Response-by-Uiniversity-Hospital-of-Wales
Page 2 · response
Published 9 February 2017
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 daily multidisciplinary Board Rounds providing a patient-centred holistic review.

Verbatim wording from the response
“Daily Board Rounds supported by a multi-disciplinary team approach are completed to provide a patient centred holistic review.”

Source location
2016-0411-Response-by-Uiniversity-Hospital-of-Wales
Page 2 · response
Published 9 February 2017
Open published response
3 Mar2015
County Durham and Darlington
Concerns raised1
1. Lack of a presumption of increased falls risk for certain classes of patients in falls risk assessments
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

Thomas Luke-Taylor · 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

Thomas Luke-Taylor, who had suffered a stroke, fell from his bed while in the Stroke Rehabilitation Ward at Bishop Auckland General Hospital, sustained a head injury and subsequently died. Concerns were raised about incorrect falls-risk assessments, inadequate supervision of a student nurse, and whether certain patients such as stroke patients should be presumed to be at increased risk of falls unless there were good reasons otherwise.

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
Lack of a presumption of increased falls risk for certain classes of patients in falls risk assessments
Wider context from the report
“In evidence the Matron was asked whether it might be preferable for the falls risk assessment form to give a presumption that certain classes of patients (for example stroke patients) were at increased risk of falls and should be considered as such unless there were good reasons to the contrary. It was her view that this would not be good practice as each and every patient should be assessed on an individual basis. Whilst that is a laudable outlook it was put to her that if there had been such a presumption then the misclassification by the original staff nurse and by the student nurse might have been avoided and this could lead either in this case or in other cases to a potentially different outcome. The matron's view was that freedom of assessment was nevertheless best practice. I indicated my concern over this issue as to whether there should be a presumption in certain cases of an increased risk of falls and that consideration of this issue would be useful. ”
Source location
Thomas Luke-Taylor · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to complete initial falls risk assessments using all available information

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 raised3

Failure of the falls risk assessment document to prompt consideration or documentation of attachments

Failure of documentation on other forms to prompt reconsideration of the falls risk assessment

Failure of the falls risk assessment document to prompt assessment of attachment relevance

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

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 account for sedative medication changes in falls risk assessment

Concerns raised1

Failure to incorporate family information into falls risk assessment

Concerns raised1

Failure to integrate and respond to the whole picture of ongoing falls risk

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

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 comprehensively assess and record falls risk and implement a clear care plan

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 raised1

Lack of a presumption of increased falls risk for certain classes of patients in falls risk assessments

Actions described in response 5

Actions described in response 2

Respondent positions 1

Actions described in response 2

Respondent positions 1

Actions described in response 4