Falls prevention plans
Lack of consistent and clear falls prevention plans in care settings, leading to varied and ineffective approaches to resident safety.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
89match
Margaret Tuck
The coroner identified the absence of a falls prevention care plan and incomplete post-fall nursing assessments and neurological observations. There were also concerns about unclear nurse responsibility and delayed communication of the fall to the consultant.
Matched on
terms: fall, plan, prevention
GIRFT recommendation
89match
Orthopaedic Trauma
Trusts should ensure that patients, over the age of 50, who sustain a fracture either from a low-energy mechanism (such as a fall from a standing height or less) or with no clear history of trauma are identified. This can be done by using radiology reports. Following identification there should be an active, robust mechanism for assessing the...
Matched on
terms: fall, plan, prevention
PFD report
85match
Gladys Rich
Concerns relate to the care home's inadequate falls risk assessment and failure to implement prevention measures or resubmit an action plan. The Falls Prevention Service did not proactively follow up, placing the onus on the patient to arrange further appointments.
Matched on
terms: fall, plan, prevention
PFD report
85match
Beryl Walsh
The coroner noted multiple missed opportunities to identify the deceased as a high falls risk, to refer her to the falls team, and to provide falls prevention equipment. No falls risk assessments or care plans had been undertaken.
Matched on
terms: fall, plan, prevention
PFD report
81match
Kenneth Cottam
The coroner noted the absence of clear and robust policies for falls prevention and management at the care home, and questioned staff understanding and consistent application of existing procedures.
Matched on
terms: fall, prevention
PFD report
81match
Ronald Houchin
The coroner noted that a falls risk assessment was not followed at Rosehill House Care Home, meaning a resident lacked assistance and supervision when mobilising and experienced multiple falls. There is a need for regular falls risk assessments and adherence to care plans.
Matched on
terms: fall, plan
PFD report
77match
James Harris
The coroner identified that care home staff did not follow a resident's falls risk care plan or post-fall protocols for seeking medical attention and offering pain relief. Insufficient staff awareness of policies and inadequate record-keeping were also noted.
Matched on
terms: fall, plan
PFD report
77match
James Vinson
Mr Vinson, despite a falls risk assessment, was not under the close supervision expected in his hospital room. Concerns were also raised regarding the unclear implementation plans for a new Enhanced Care/Observation Standard Operating Procedure.
Matched on
terms: fall, plan
PFD report
77match
Brenda Gowan
Concerns included insufficient care provision, unaddressed falls risks and lack of equipment in the discharge plan for a stroke patient, alongside a failure to involve family or review the plan when care needs changed.
Matched on
terms: fall, plan
PFD report
73match
Freda Cordy
The coroner noted Mrs Cordy was placed in a care home with 2-hourly checks despite needing constant supervision. No specific falls risk assessment was undertaken despite a falls history, and only a floor mattress was provided for prevention.
Matched on
terms: fall, prevention
PFD report
73match
Patricia Webb
The coroner identified insufficient enhanced observation for high falls-risk patients and a lack of evidence for the implementation of plans for increased observation and meaningful activity. There were also concerns about the effectiveness of non-slip hospital footwear.
Matched on
terms: fall, plan
PFD report
73match
Harold Wonfor
The coroner noted inadequate, incomplete, or unenforced falls risk assessments led to five patient deaths on a ward, with policies and procedures for falls prevention being insufficient, especially for vulnerable patients, and lacking adequate monitoring and enforcement.
Matched on
terms: fall, prevention
PFD report
73match
Jean Cutler
The coroner identifies an inconsistent approach to falls prevention for wheelchair users inside the nursing home, with an inadequate reliance on staff intervention. Concerns also relate to the insufficient post-incident investigation and incomplete falls risk assessment documents.
Matched on
terms: fall, prevention
PFD report
73match
Graham Jones
The coroner raised concerns regarding the sufficiency of falls prevention measures and staff understanding of post-fall protocols on the surgical ward, particularly the need for medication review. Concerns were also noted about the adequacy of safety information handover between wards during patient transfers.
Matched on
terms: fall, prevention
PFD report
73match
Alan Jones
The coroner identified a lack of a multidisciplinary approach to managing Mr. Jones' increasing confusion and high falls risk, noting that required supervision levels were not met due to insufficient staffing. This contributed to multiple falls, reflecting a failure in the falls prevention strategy.
Matched on
terms: fall, prevention
PFD report
69match
Hilda Thompson
An incomplete management plan on admission led to the patient being wrongly identified as not a falls risk, resulting in a 10-day delay for a full falls assessment. The coroner also noted poor record keeping.
Matched on
terms: fall, plan
PFD report
69match
Christine Street
The coroner identified that a healthcare assistant did not adhere to the Trust's observation policy for a patient with mental health illness, leading to an unwitnessed fall. There was also a significant lack of documentation regarding patient observations, contrary to Trust policy and national guidance.
Matched on
terms: fall
CQC enforcement action
69match
Warning Notice: Kettering General Hospital NHS Foundation Trust
The Care Quality Commission (CQC) published a report following an inspection of medical services at Kettering General Hospital NHS Foundation Trust in May due to concerns around patient falls. Following the inspection, the trust was issued with a warning notice requiring improvements around the assessment and management of risk, implementation of falls prevention, and learning from serious incidents....
Matched on
terms: fall, prevention
CQC action
68match
Trent Lodge Residential Care Home
We recommend that the service finds out more about training for staff, based on current best practice, in relation to the risk assessment and prevention of falls.
Matched on
terms: fall, prevention
PFD report
65match
May Gibson
The coroner noted failures in obtaining and utilising community care assessments, developing an adequate care plan for Mrs Gibson, and conducting proper risk assessments and reduction plans. Concerns were also raised regarding a lack of cohesive management and insufficient staff training and supervision within the care home.
Matched on
terms: plan
PFD report
65match
Ethel Cross
The presence of wheeled chairs on wards where elderly patients at high risk of falls are cared for, and the lack of available alarms for these patients when one-to-one assistance is needed, raises concerns.
Matched on
terms: fall
PFD report
65match
John William Tugwell
The coroner noted that a resident identified as a falls risk, with a history of previous falls, was allowed unsupervised access to stairs within the care home.
Matched on
terms: fall
PFD report
65match
Edna Bulmer
The coroner noted inconsistent recording of fall risk levels, delayed implementation of identified risk minimisation measures, and a lack of risk assessment review after subsequent fall incidents.
Matched on
terms: fall
PFD report
65match
Emmeline Hampson
The coroner identified a lack of procedures for reviewing falls risk assessments and documentation following a fall or significant change in a resident's condition. Concerns also included issues with alarm systems for falls and call bells, and insufficient training for agency staff on relevant procedures.
Matched on
terms: fall
PFD report
65match
Howell Fisher
The report identifies insufficient staffing for a high-risk falls patient, meaning one-to-one nursing was not consistently delivered. There was also a lack of handover material on falls risk between hospitals and no formal risk assessments after successive falls.
Matched on
terms: fall
PFD report
65match
Peter King
The coroner noted that falls risk assessments were often inadequate, incomplete, or not enforced, and that interventions to prevent falls were either not recognised or not implemented. Specific concerns included poor documentation of precautions, lack of referrals, and unaddressed escalation of safety needs for an observable bed.
Matched on
terms: fall
PFD report
65match
Edna Evans
Incomplete staff training on falls risk was noted, alongside inconsistent categorisation of residents for falls risk despite multiple incidents. There was no policy for reassessment following further falls.
Matched on
terms: fall
PFD report
65match
Evelyn Ross
The coroner identified ward staffing shortages, insufficient medical documentation, and a lack of a clear system for regular orthogeriatric consultant reviews to escalate deterioration. The trust also did not follow its own falls risk policy.
Matched on
terms: fall
PHSO casework decision
64match
P-003134 - University Hospitals of Liverpool Group
Mrs A complained the Trust lacked a sufficient falls plan, leading to her brother's fatal fall. She also alleged insufficient tests were done to establish injury extent and provide pain relief before his death.
Matched on
terms: fall, plan
PFD report
61match
Thomas Maher
Concerns included missing medical records, inconsistent falls risk assessments, and an inactive fall alarm during a patient's fall. The coroner also identified difficulties with inter-hospital patient transfers and incompatible electronic and paper patient record systems.
Matched on
terms: fall
PFD report
61match
Vincent Smith
The coroner noted insufficient steps to assess and act upon Mr Smith's vulnerability following a fall. Concerns were raised about reviewing the admissions policy for resident suitability and the falls risk assessment policy with associated staff training.
Matched on
terms: fall
PFD report
61match
Roger Tombs
The coroner raised concerns that placing fall sensor mats on top of crash mats at Sunrise of Knowle may reduce their effectiveness, potentially failing to alert staff when vulnerable residents mobilise and increasing the risk of falls and injury.
Matched on
terms: fall
PFD report
61match
Ivy Mitchell
The coroner noted inaccurate falls risk documentation, a lack of staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes following a fall. There was also a lack of understanding regarding triggers for community nutrition team referrals.
Matched on
terms: fall
PFD report
61match
Ida Toole
The coroner identified that a high fall risk resident did not have a sensor mat due to a policy linking provision to mental capacity, recommending an urgent review of this policy.
Matched on
terms: fall
PFD report
61match
Kenneth Swift
There was a lack of immediately available falls sensors for patients assessed at high risk of falling, resulting in patients like Mr Swift being placed on a waiting list. This limited staff awareness of unsupervised mobilisation and poses a risk to other patients.
Matched on
terms: fall
PFD report
61match
Kathleen Devine
Concerns were raised regarding the failure of staff to record observations for a high falls risk resident, the removal of a falls mat and sensor, and the inadequate quality of handover instructions provided to agency staff.
Matched on
terms: fall
PFD report
61match
Henry Honour
The coroner noted multiple deaths on a hospital ward caused by falls, citing inadequate, incomplete, or unenforced falls risk assessments. Specific issues included perfunctory initial assessments, inappropriate bedrail use, and a lack of updated assessments or protective measures after a fall.
Matched on
terms: fall
PFD report
61match
John Preece
The coroner noted insufficient staff knowledge and training in falls management and neuro observations, leading to inadequate monitoring and delayed medical assistance for a patient with a suspected head injury. Risks were also identified for medically unwell mental health patients due to poor training and the inability to implement the National Early Warning System.
Matched on
terms: fall
PFD report
61match
Andrew Hogg
The coroner raised concerns regarding the absence of an adequate falls assessment policy and a clear escalation pathway after a patient experienced sequential falls, noting that each incident was dealt with reactively without proactive risk reduction.
Matched on
terms: fall
Committee recommendation
61match
#7 - 79th Report - Supporting people with frailty outside hospitals
For all patients diagnosed with severe frailty, the GP contract requires GPs to do a clinical review. This includes a review of the patient’s medication, a falls risk assessment and a discussion with the patient of the benefits of having an enriched summary care record that provides healthcare professionals with access to core details about the patient (medications,...
Matched on
terms: fall
CQC action
61match
The York Hospital
The trust must ensure ongoing patient safety concerns such as falls, pressure ulcers and healthcare care acquired infections are addressed in a timely way and all possible actions are taken to address concerns.
Matched on
terms: fall
CQC action
61match
Scarborough Hospital
The trust must ensure ongoing patient safety concerns such as falls, pressure ulcers and healthcare care acquired infections are addressed in a timely way and all possible actions are taken to address concerns.
Matched on
terms: fall
PHSO casework decision
60match
P-004658 - An independent provider in the Hammersmith and Fulham area
A Care Home failed to properly assess and manage a resident's known falls risk, leading to injuries, discomfort, and delayed 1:1 care for her late uncle.
Matched on
terms: fall
CQC action
60match
Lady Ida Lodge
Monitoring which was supposed to happen within the 48-hour period following a fall had not been completed. Accidents and incidents were not triggering a review of the risk assessment and associated care plan for this person.
Matched on
terms: fall, plan
PHSO casework decision
60match
P-001563 - Mid and South Essex NHS Foundation Trust
The complainant alleged staff left her father's bed rails down, contrary to his care plan, causing him to fall from bed and subsequently die.
Matched on
terms: fall, plan
PFD report
57match
Laura Hill
Falls Risk Assessments were not carried out for Mrs Hill during her hospital stay, specifically on admission or ward transfer, despite existing staff training on the procedure.
Matched on
terms: fall
PFD report
57match
Nellie Travis
The coroner noted the hospital's Falls Risk Assessment tool was subjective and its utility depended on individual nurse opinion, especially when completed by non-Trust staff. A more objectively assessed tool was identified as necessary.
Matched on
terms: fall
PFD report
57match
James McArdle
The withdrawal of a coloured wrist band system for identifying elderly patients at risk of falls, without replacement, removed a layer of protection and may increase the risk of future falls and deaths.
Matched on
terms: fall
PFD report
57match
Ian Reid
The coroner noted delays in revision hip surgery due to unavailable information on the type and specification of the deceased's implants. Concerns were raised regarding the absence of a formal patient document or a hospital system for accessible implant details.
Matched on
terms: plan
PFD report
57match
Martin McCabe
No falls risk assessment was carried out upon the patient's admission to ward 15, with staff relying on an outdated assessment that did not include crucial information about recent falls and new medication.
Matched on
terms: fall