PFD report

John McKinlay · Prevention of Future Deaths report

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Issued 1 May 2026•Birmingham and Solihull

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to investigate falls and implement adequate learning actions
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Inadequate safety incident investigations
  2. Failure to provide appropriate observation in accordance with falls risk assessments and care plans
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Unreliable patient observation arrangements
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 recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Provide falls training covering the learning identified from the incidents, with staff attendance completed or being arranged.

    Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 June 2026.
  2. Action

    Review every reported patient fall through local and central falls-team processes, identify learning, and implement appropriate corrective actions.

    Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 June 2026.
  3. Action

    Disseminate fall-related learning and required actions to ward staff through Listen Learn Share forms and electronic RADAR alerts.

    Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 June 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Existing local and corporate falls reviews, learning, and actions were considered sufficient; no further action was proposed.

    Stated by University Hospitals Birmingham NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to investigate falls and implement adequate learning actions

Wider context from the report

“The evidence from witnesses was that Mr McKinlay had a total of 4 falls whilst an inpatient at the University Hospitals of Birmingham: on the 11th September 2025 at Good Hope Hospital, 28th September 2025 at Birmingham Heartlands Hospital and on the 10th and 12th November 2025 at Queen Elizabeth Hospital. Some, potentially all, of the falls occurred when Mr McKinlay was not receiving the appropriate level of observation in accordance with his falls risk assessment and care plan. He sustained a femur fracture requiring operative fixation from the fall on the 11th September and an acute bleed of a pre-existing subdural haemorrhage on the 28th September. He did not have any investigations into the November falls as he was already receiving end of life care and there was no clinical evidence of injury. There has been a mortality review of the events at Good Hope Hospital, including the fall on the 11th September. However, evidence has not been provided of investigations into the falls at Birmingham Heartlands Hospital and Queen Elizabeth Hospital. It therefore cannot be determined that appropriate lessons have been learnt and adequate action taken creating a risk the situation has not improved. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Inadequate safety incident investigations.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide appropriate observation in accordance with falls risk assessments and care plans

Wider context from the report

“The evidence from witnesses was that Mr McKinlay had a total of 4 falls whilst an inpatient at the University Hospitals of Birmingham: on the 11th September 2025 at Good Hope Hospital, 28th September 2025 at Birmingham Heartlands Hospital and on the 10th and 12th November 2025 at Queen Elizabeth Hospital. Some, potentially all, of the falls occurred when Mr McKinlay was not receiving the appropriate level of observation in accordance with his falls risk assessment and care plan. He sustained a femur fracture requiring operative fixation from the fall on the 11th September and an acute bleed of a pre-existing subdural haemorrhage on the 28th September. He did not have any investigations into the November falls as he was already receiving end of life care and there was no clinical evidence of injury. There has been a mortality review of the events at Good Hope Hospital, including the fall on the 11th September. However, evidence has not been provided of investigations into the falls at Birmingham Heartlands Hospital and Queen Elizabeth Hospital. It therefore cannot be determined that appropriate lessons have been learnt and adequate action taken creating a risk the situation has not improved. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unreliable patient observation arrangements.

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

Provide falls training covering the learning identified from the incidents, with staff attendance completed or being arranged.

Verbatim wording from the response

“On 17 November 2025 the ward manager completed their local investigation into the incident and completed a Listen Learn Share form highlighting the non-adherence to the falls procedure and reminding staff of the importance of ensuring that relevant assessments were completed and a recommendation that they all re-familiarise themselves with the Trust falls procedure. The specific learning identified included; that staff must familiarise themselves with the post fall retrieval procedure to ensure that they are retrieving patients from the floor using the correct methods, to ensure that documentation is thorough in order to record specifics about a patient fall including what footwear the patient was wearing, what exactly was discussed with the patient’s next of kin, and also ensuring post fall observations are completed as per the Trust standards.”

Source location

Response from University Hospitals of Birmingham NHS Foundation Trust
Page 5 · response
Published 30 June 2026

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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 every reported patient fall through local and central falls-team processes, identify learning, and implement appropriate corrective actions.

Verbatim wording from the response

“All patient falls within our organisation are reviewed locally and also centrally by our governance and falls teams. We have a dedicated falls team and part of their role is to review every reported incident where a patient has suffered a fall. The service runs Monday to Friday. Each of Mr McKinley’s falls were incident reported and reviewed by a member of the falls team in a timely manner prior to the incident being closed.”

Source location

Response from University Hospitals of Birmingham NHS Foundation Trust
Page 2 · response
Published 30 June 2026

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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

Disseminate fall-related learning and required actions to ward staff through Listen Learn Share forms and electronic RADAR alerts.

Verbatim wording from the response

“A Listen Learn Share form was also completed with the learning identified and actions required and this was circulated to all staff to read.”

Source location

Response from University Hospitals of Birmingham NHS Foundation Trust
Page 3 · response
Published 30 June 2026

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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

Escalate staffing and patient-dependency pressures daily while reviewing ward establishment levels to address increased dependency.

Verbatim wording from the response

“The situation was escalated to the senior nursing team and contact was made with an external Trust to request a registered mental health nurse to support the ward. Cover was provided on this date. We are aware of an increase in dependency of patients on this ward and a review is being undertaken by the Matron of the establishment level with a view to changes in this to meet the changes in patient cohort.”

Source location

Response from University Hospitals of Birmingham NHS Foundation Trust
Page 4 · response
Published 30 June 2026

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

Reinforce ward handovers remaining inside patient bays through daily safety-huddle reminders and stay-in-the-bay armbands, with compliance monitoring.

Verbatim wording from the response

“As set out within the Senior Sister’s statement shared with the Coroner’s office on 16 December, she spoke to staff to ascertain how the fall occurred. In response, staff reflected that they had undertaken a handover outside of the bay instead of inside the bay which ultimately led to Mr McKinlay being able to get up unaided. The whole team were reminded of the importance of staying in bays during subsequent daily safety huddles. Stay in the bay arm bands were also introduced in order to reinforce this further. The Senior Sister continues to monitor compliance with this and the falls team have confirmed they have received no further incidents from this ward in relation to falls occurring when staff are leaving their designated area to handover.”

Source location

Response from University Hospitals of Birmingham NHS Foundation Trust
Page 3 · response
Published 30 June 2026

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 local and corporate falls reviews, learning, and actions were considered sufficient; no further action was proposed.

Verbatim wording from the response

“A summary of the incident and findings from the scoping were also presented at a weekly Patient Safety Incident Review Group meeting on 8 January 2026. This meeting is chaired by a Deputy Chief Medical Officer and attended by specialty medical directors, senior nursing teams and governance leads. After considering the incident, the group concluded that there was no requirement for a formal investigation as the incident had already been thoroughly reviewed locally and the team had already reflected on the incident and put appropriate actions in place to prevent a similar incident occurring.”

Source location

Response from University Hospitals of Birmingham NHS Foundation Trust
Page 3 · response
Published 30 June 2026

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 falls team considered no further investigation necessary from its perspective, leaving further investigation to the ward team’s local process.

Verbatim wording from the response

“The falls team reviewed the incident on Monday 29 September 2025 and the incident was deemed to be low harm in light of the NORSe neurosurgery review above, therefore, no further investigation was deemed to be required by the falls team and this remained for local investigation by the ward team.”

Source location

Response from University Hospitals of Birmingham NHS Foundation Trust
Page 4 · response
Published 30 June 2026

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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

No further action was considered necessary for the November fall because the patient was receiving end-of-life care under the medical team’s plan.

Verbatim wording from the response

“On the morning of 10 November 2025 the falls team contacted the ward team confirming that they had reviewed the incident and downgraded the severity of the fall from moderate to low harm as there were no significant injuries noted following medical reviews. Again, the falls team reviewed the RADAR form, the clinical noting, observations recorded and assessments completed as well as reading the notes to understand the course of events and management plan going forward. At this stage it was recorded that Mr McKinlay continued on the end-of-life pathway and no further action was deemed necessary as per the medical team plan. It is noted that Mr McKinlay’s daughter was made aware of the fall at 13.35 hours.”

Source location

Response from University Hospitals of Birmingham NHS Foundation Trust
Page 4 · response
Published 30 June 2026

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026