Recurring concern

Unreliable response to falls at elderly people's homes

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First reported 14 Feb 2019•Latest report 12 Aug 2024

Definition

What this concern includes

Includes failures in the dedicated response to falls involving elderly people at home, including role and responsibility definition, initial assessment, recognition of serious injury, communication of assessment limitations, ambulance escalation and related response guidance or competence controls.

Not included

Excludes generic care-provider role ambiguity where the asserted concern is not the response to a fall at an elderly person's home.
Excludes falls prevention, home-environment hazards and post-hospital treatment where the response to the fall is not deficient.
Excludes generic training, staffing or communication deficiencies unless they directly impair the dedicated response to an elderly person's fall.
Excludes unrelated clinical assessment or ambulance-response failures not connected to an elderly person who has fallen at home.

Reports: 3
Individual concerns: 4
Date range: 2019–2024
Stated actions: 5

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.

General Pharmaceutical Council1

Medequip Assistive Technology Limited1

NHS Central East Integrated Care Board1

Orchard 2000 Pharmacy1

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.

12 Aug2024
Liverpool and the Wirral
Concerns raised2
1. Failure of care responders to identify serious injuries from falls or recognise the limits of their diagnostic ability
2. Failure to communicate the limits of responders' diagnostic ability to ambulance services
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

Douglas ARMSTRONG · 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

Douglas ARMSTRONG had an unwitnessed fall at home on 16 December 2023 and sustained a fractured neck of femur that was not identified by care agency responders or a district nurse. His hospital arrival and likely surgery were delayed by around 18 hours, and he died in hospital on 5 January from aspiration pneumonia resulting from the injury. The principal concern was that responders may lack the skills, knowledge, training, or communication needed to identify such injuries or recognise when further assessment is required.

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 care responders to identify serious injuries from falls or recognise the limits of their diagnostic ability
Wider context from the report
“Following his fall at home the Deceased was visited by two representatives of the care agency. They did not appreciate that he had suffered a fractured neck of femur. They placed more reliance than was justified upon his assertion that he had not hurt himself and was not in pain. The information supplied during their verbal communication with the ambulance service did not result in the latter appreciating the need for a personal attendance or visual assessment. Fractured neck of femur is a common consequence of falls in the elderly and requires prompt attention. Those providing a response system should have the skills, knowledge and training necessary to identify the problem or to appreciate that they cannot do so, and to communicate the limits of their diagnostic ability to the ambulance service. I was told that the responders acted in accordance with their existing training and have had no additional training since these events, nor was I told that any is planned. I am concerned that responders attending a similar call might be unable to assist effectively and would appreciate their employers addressing this by considering whether opportunities exist to improve the situation. ”
Source location
Douglas ARMSTRONG · 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 to communicate the limits of responders' diagnostic ability to ambulance services
Wider context from the report
“Following his fall at home the Deceased was visited by two representatives of the care agency. They did not appreciate that he had suffered a fractured neck of femur. They placed more reliance than was justified upon his assertion that he had not hurt himself and was not in pain. The information supplied during their verbal communication with the ambulance service did not result in the latter appreciating the need for a personal attendance or visual assessment. Fractured neck of femur is a common consequence of falls in the elderly and requires prompt attention. Those providing a response system should have the skills, knowledge and training necessary to identify the problem or to appreciate that they cannot do so, and to communicate the limits of their diagnostic ability to the ambulance service. I was told that the responders acted in accordance with their existing training and have had no additional training since these events, nor was I told that any is planned. I am concerned that responders attending a similar call might be unable to assist effectively and would appreciate their employers addressing this by considering whether opportunities exist to improve the situation. ”
Source location
Douglas ARMSTRONG · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Jul2023
East Riding and Hull
Concerns raised1
1. Lack of clarity about roles, responsibilities and required actions during falls at elderly service users' homes
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 4
1. Action
  Remind inspectors to discuss pharmacy procedures for responding when delivery agents find service users fallen or otherwise at risk.
  Stated by General Pharmaceutical CouncilStated planned
2. Action
  Assess the pharmacy’s safeguarding risks and factor the concern into inspection timing and focus decisions.
  Stated by General Pharmaceutical CouncilStated planned
3. Action
  Inform delivery agents of their duty to contact emergency services and notify the pharmacist on duty after identifying an emergency.
  Stated by Excel Chemists T/A Orchard 2000 PharmacyStated completed
1. Action
  Enrol all delivery agents on the Delivering Medicines Safely and Effectively training programme.
  Stated by Excel Chemists T/A Orchard 2000 PharmacyStated completed
Respondent positions 3
1. Position
  The regulator’s role covers registered pharmacists and pharmacy technicians, not unregistered delivery drivers.
  Stated by General Pharmaceutical CouncilOutside remit
1. Position
  Delivery drivers are not generally expected to receive training specifically for managing a service-user’s fall at home or to enter patients’ homes.
  Stated by General Pharmaceutical CouncilDisputes the concern
2. Position
  The pharmacy defines support staff roles, while its Superintendent pharmacist is responsible for ensuring their training and competencies meet requirements.
  Stated by General Pharmaceutical CouncilRedirects responsibility
AI-generated summary

Harold Wilberforce · 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

Harold Wilberforce fell at home on 16 January 2023, sustained a broken hip and was taken to hospital, where he contracted bronchopneumonia and died on 28 January 2023. Concerns included the lack of medical examination after the fall, the pharmacy delivery agent’s lack of awareness of his dementia, the absence of relevant staff training, and unclear roles and responsibilities when elderly service users are found to have fallen.

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 clarity about roles, responsibilities and required actions during falls at elderly service users' homes
Wider context from the report
“(3) I am concerned that a lack of clarity exists in respect of the roles and responsibilities of persons attending upon the home addresses of elderly service users, particularly in the context of what action should be taken when someone is found to have fallen. ”
Source location
Harold Wilberforce · 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
Remind inspectors to discuss pharmacy procedures for responding when delivery agents find service users fallen or otherwise at risk.

Verbatim wording from the response
“We will also remind our inspectors to make sure that they include, through our ongoing inspections, discussions about whether a pharmacy has SOPs in place to support delivery agents/drivers and wider teams to know what to do and who to contact if they find that a service user has had a fall or is at risk in other ways. The inspectors do currently routinely ask about how pharmacies ensure that children and vulnerable adults are safeguarded. This means that we can check if pharmacies are proactively considering how to manage the risks associated with these situations.”

Source location
Response from General Pharmaceutical Council
Page 3 · response
Published 18 July 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
Assess the pharmacy’s safeguarding risks and factor the concern into inspection timing and focus decisions.

Verbatim wording from the response
“From what has been described to us, on this occasion it does appear that there has been a failure to safeguard a vulnerable service-user. As the issues you have raised fall more into the category of how the pharmacy is being operated, we have referred the matter to our local Inspector who covers this particular pharmacy. They will assess the risks posed by the issues you have described, and determine what follow-up action may be appropriate. The Inspector will also factor this information into their decision-making”

Source location
Response from General Pharmaceutical Council
Page 1 · response
Published 18 July 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
Inform delivery agents of their duty to contact emergency services and notify the pharmacist on duty after identifying an emergency.

Verbatim wording from the response
“As an organisation, we have taken steps to address this by making our delivery agents aware of their duty to contact emergency services and inform the pharmacist on duty as soon as practical.”

Source location
Response from Orchard 2000 Pharmacy
Page 1 · response
Published 18 July 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
Enrol all delivery agents on the Delivering Medicines Safely and Effectively training programme.

Verbatim wording from the response
“We have also contacted our staff training providers, the NPA, to identify any necessary update course for our delivery agents. They have responded by making us aware of a training programme titled: Delivering Medicines Safely and Effectively. We have reviewed the content of the course and are satisfied that this covers all the concerns and provides clarity for our staff in these circumstances.”

Source location
Response from Orchard 2000 Pharmacy
Page 1 · response
Published 18 July 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
The regulator’s role covers registered pharmacists and pharmacy technicians, not unregistered delivery drivers.

Verbatim wording from the response
“In addition, not all those who work within a pharmacy company, such as delivery drivers, are required to be registered professionals, and our role only covers individuals who are registered pharmacists or pharmacy technicians.”

Source location
Response from General Pharmaceutical Council
Page 1 · response
Published 18 July 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
Delivery drivers are not generally expected to receive training specifically for managing a service-user’s fall at home or to enter patients’ homes.

Verbatim wording from the response
“This matter relates to pharmacy support staff. The roles and responsibilities of pharmacy support staff, such as delivery drivers, will be defined by the pharmacy. They, however, must be suitably qualified for the roles that they do. GPhC requirements for the education and training of pharmacy support staff includes being able to recognise and raise appropriate safeguarding concerns, particularly involving vulnerable adults. However, delivery drivers would not be expected to receive training specifically with how to manage a situation where a service-user has had a fall at home, and would also not normally enter patient’s homes.”

Source location
Response from General Pharmaceutical Council
Page 1 · response
Published 18 July 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
The pharmacy defines support staff roles, while its Superintendent pharmacist is responsible for ensuring their training and competencies meet requirements.

Verbatim wording from the response
“This matter relates to pharmacy support staff. The roles and responsibilities of pharmacy support staff, such as delivery drivers, will be defined by the pharmacy. They, however, must be suitably qualified for the roles that they do. GPhC requirements for the education and training of pharmacy support staff includes being able to recognise and raise appropriate safeguarding concerns, particularly involving vulnerable adults. However, delivery drivers would not be expected to receive training specifically with how to manage a situation where a service-user has had a fall at home, and would also not normally enter patient’s homes.”

Source location
Response from General Pharmaceutical Council
Page 1 · response
Published 18 July 2023
Open published response
14 Feb2019
Milton Keynes
Concerns raised1
1. Unavailability of a home-based falls response service
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
  Operate a 24/7 Home 1st Rapids service providing rapid triage, home attendance, assessment and escalation for acute falls.
  Stated by NHS Central East Integrated Care BoardStated completed
Respondent positions 1
1. Position
  Existing commissioned services sufficiently replace the discontinued falls service, covering acute, preventative and non-urgent community fall needs.
  Stated by NHS Central East Integrated Care BoardExisting arrangements considered sufficient
AI-generated summary

Douglas Albert Walter MINNS · 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

Douglas Albert Walter MINNS, aged 93, fell at home on 21 August 2018 and made an emergency call. He was attended by ambulance after approximately four hours, taken to hospital with subarachnoid and subdural bleeding, and died there on 22 August 2018. The principal concern was the withdrawal of a falls service and the resulting delay in responding to people who had fallen, particularly amid strains on the ambulance service.

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
Unavailability of a home-based falls response service
Wider context from the report
“During the course of the evidence it was explained to me that the provision of a falls service was withdrawn some years ago, the service would provide for someone to attend the home of the person who had fallen, get them on their feet, assess their wellbeing, serve a cup of tea and get them back into bed if required. If they required more urgent treatment, they would report to the ambulance service. The withdrawal of the service puts patient's lives at risk and, in view of the strains on the ambulance service, consideration should be given to re-introducing it. It is unacceptable for a 93 year old man to be left lying on the floor for four hours before someone responds. ”
Source location
Douglas Albert Walter MINNS · 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
Operate a 24/7 Home 1st Rapids service providing rapid triage, home attendance, assessment and escalation for acute falls.

Verbatim wording from the response
“• A Home 1st Rapids service provided by our community provider, CNWL, comprising of experienced nurse practitioners and prescribers, who respond to a call from a GP, ambulance services or other allied health professional.”

Source location
2019-0052-Response-by-Milton-Keynes-CCG
Page 1 · response
Published 2 June 2019
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 commissioned services sufficiently replace the discontinued falls service, covering acute, preventative and non-urgent community fall needs.

Verbatim wording from the response
“I hope the above description of commissioned services provides suitable assurance that although the original falls services was discontinued, it has been replaced by a 24/7 Home 1st Rapids service to deal with acute episodes of falling in the community; supported by two in office hours services which focus on prevention and non-urgent needs. The Home 1st Rapids service reflects the objectives of the original falls service in that they attend the home, carry out an assessment, make the individual comfortable and call an ambulance if required.”

Source location
2019-0052-Response-by-Milton-Keynes-CCG
Page 2 · response
Published 2 June 2019
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure of care responders to identify serious injuries from falls or recognise the limits of their diagnostic ability

Failure to communicate the limits of responders' diagnostic ability to ambulance services

Concerns raised1

Lack of clarity about roles, responsibilities and required actions during falls at elderly service users' homes

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Unavailability of a home-based falls response service

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

Actions described in response 4

Respondent positions 3

Actions described in response 1

Respondent positions 1