Falls prevention plans
Lack of consistent and clear falls prevention plans in care settings, leading to varied and ineffective approaches to resident safety.
Source spread
Where this theme appears
This theme appears across 12 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
102 PFD reports
2 committee recs
21 CQC actions
1 PPO rec
2 Scottish FAIs
5 DHR recs
47 PHSO decisions
7 LGO/SPSO decisions
3 CQC enforcement actions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Prevention of Future Deaths reports(102)— showing 50 strongest matches
May Gibson
Concerns: 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.
Overdue
Ethel Cross
Concerns: 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.
Overdue
Laura Hill
Concerns: 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.
Response (Stockport NHS Foundation Trust): • Nurses involved were formally counselled for failing to follow Trust policy regarding the implementation of the falls risk assessment on admission and its update upon ward transfer. • An … (AI summary)
Responded
John William Tugwell
Concerns: 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.
Overdue
Nellie Travis
Concerns: 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.
Overdue
Thomas Maher
Concerns: 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.
Response (Central Manchester University Hospital NHS Trust): • The Trust implemented a new process for scanning records of deceased patients and high-level incidents into the electronic patient record system, with a long-term aim for all patient records … (AI summary)
Responded
James McArdle
Concerns: 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.
Response (Wirral University Teaching Hospitals NHS Foundation Trust): • The Trust resolved in October 2013 to use red wristbands for allergies only, communicating this change to staff. • The Trust implemented new assisted technology and improved comfort checks, … (AI summary)
Responded
William Beckwith
Concerns: The coroner noted a lack of formal assessment for a frail, elderly patient's abilities, home environment, or post-discharge needs before early morning discharge. The department also lacked a formal policy for risk-assessing such discharges.
Response: • The Emergency Department had guidance in place since 2012 for assessing elderly patients presenting after a fall. • A multidisciplinary review of this guidance is currently in progress. • … (AI summary)
Responded
Ian Reid
Concerns: 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.
Response (Department of Health): • NHS England established a reference group to develop national standards for operating department practice. • These national standards will include a prosthesis identification process to ensure details of all … (AI summary)
Responded
Edna Bulmer
Concerns: 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.
Overdue
Hilda Thompson
Concerns: 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.
Overdue
Martin McCabe
Concerns: 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.
Overdue
Thomas Taylor
Concerns: The coroner noted concerns that the falls risk assessment form does not presume increased risk for certain patient classes, which could lead to misclassification and potentially different outcomes.
Overdue
Emmeline Hampson
Concerns: 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.
Overdue
Jeanne Summers
Concerns: The report highlights a lack of clear patient assessment before discharge and incomplete physiotherapy records. Further concerns relate to patients using inappropriate footwear for mobilisation, staff leaving patients mid-transfer, and inadequate training for those conducting incident investigations.
Overdue
Robert Payne
Concerns: Repeated falls occurred despite the deceased being identified as high risk, with one fall necessitating further surgery. A ward transfer also occurred at 1 am without a transfer document, preceding an unwitnessed fall.
Overdue
Howell Fisher
Concerns: 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.
Overdue
Vincent Smith
Concerns: 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.
Overdue
Milly Zemmel
Concerns: The Trust's internal investigation did not fully identify failures in basic medical care, including a lack of appropriate one-to-one supervision for a patient with acute confusion and blindness, and inadequate information handover between shifts.
Response (Response Pennine Acute Hospitals): • The Trust revised its Incident Reporting and Investigation Policy in June 2015, establishing independent investigation teams and providing root cause analysis training. • A 'Safety Huddle' was introduced for … (AI summary)
Responded
Christine Street
Concerns: 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.
Response (Brighton and Sussex University Hospitals NHS Trust): • The Trust followed up with nursing and medical staff regarding documentation quality and understanding of observation policies. • Study days were held for nurses, and teaching sessions were run … (AI summary)
Responded
Freda Cordy
Concerns: 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.
Overdue
Margaret Tuck
Concerns: 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.
Response (Barths Health NHS Trust): • The Trust implemented new falls assessment paperwork, introduced high-risk wristbands, and now nurses high-risk patients in bays allowing direct observation. • Staff allocation was revised to ensure each patient … (AI summary)
Responded
Roger Tombs
Concerns: 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.
Response (Sunrise Senior Living): • Sunrise Senior Living stated it took steps immediately following the inquest to address concerns regarding the placement of sensor mats on crash mats. • Sunrise Senior Living invited the … (AI summary)
Response (Roger Tombs): • The Falls Team reviewed its practice regarding advice and training on sensor mats and found it to be consistent and accurate. • A guidance document outlining good practice in … (AI summary)
Overdue
Patricia Webb
Concerns: 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.
Overdue
Ivy Mitchell
Concerns: 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.
Response (Fairfield View Care Centre): • The care centre audited documentation related to falls and mobility for all service users. • Senior staff attended a meeting on documentation and falls procedures, and this information was … (AI summary)
Overdue
Ida Toole
Concerns: 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.
Overdue
Francis Langley
Concerns: The coroner noted inconsistencies in bed rail risk assessments between hospital sites and contradictory responses within one hospital's assessment forms. Concerns were raised that the decision not to use bed rails did not sufficiently account for the patient's immobility, paralysis, and involuntary movements.
Response (Great Western Hospital NHS Trust): • The Trust implemented the nursing personalised care plan documentation, which includes bed rail and falls assessments, on Forest and Orchard wards from July 2017. • The Trust stated it … (AI summary)
Responded
Kenneth Swift
Concerns: 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.
Response (York Teaching Hospital NHS Trust): • The Trust purchased an additional 30 complete sensor kits. • It agreed a new management system with the Equipment Library for the storage and supply of fall sensors. • … (AI summary)
Responded
James Harris
Concerns: 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.
Response (Care First Class UK): • The organisation has implemented read and sign sheets for staff to acknowledge care plans within 72 hours of a resident's arrival. • The falls protocol has been distributed to … (AI summary)
Response (CQC): • The Care Quality Commission (CQC) conducted a comprehensive inspection of Cherry Lodge Care Home in August 2017, bringing forward its scheduled date. • Cherry Lodge Care Home implemented new … (AI summary)
Responded
James Vinson
Concerns: 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.
Response (City Hospitals Sunderland NHS Trust): • The Trust is developing an Enhanced Care Standard Operating Procedure (SOP) and is currently piloting the draft SOP on several wards. • The Trust has set a target date … (AI summary)
Responded
Kenneth Cottam
Concerns: 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.
Response (Coxbench Hall Residentail Home): • The organisation stated that policies and procedures for falls prevention and management were in place and had been provided to the Coroner. • It confirmed that staff sign a … (AI summary)
Responded
Harold Wonfor
Concerns: 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.
Response (Response East Kent NHS Trust): • The Trust continues work on timely and adequate falls risk assessments and monitors patient falls rates and harm monthly. • The Trust reviewed its Falls Risk Assessment and Care … (AI summary)
Responded
Kathleen Devine
Concerns: 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.
Response (Bloom Care): • A precise care plan has been implemented for residents using crash or sensor mats, detailing guidance for staff on correct placement and equipment use. • Daily handover sheets now … (AI summary)
Overdue
Henry Honour
Concerns: 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.
Overdue
Peter King
Concerns: 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.
Response (East Kent NHS Trust): • The Trust reviewed its Falls Risk Assessment and Care Plan (FRACP) to incorporate National Institute Health and Care Excellence (NICE) guidance. • A quality improvement programme named "Fallstop" was … (AI summary)
Responded
Gladys Rich
Concerns: 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.
Response (Avenue House Care Home): • The care home stated it would contact the Falls Team after sending referrals and action plans to confirm receipt and ascertain intended actions. • The care home stated it … (AI summary)
Overdue
Beryl Walsh
Concerns: 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.
Response (Beechwood Lodge): • Beechwood Lodge has implemented more robust risk assessments for residents who have experienced falls. • New risk assessments are in place in all care plans concerning safety equipment. • … (AI summary)
Responded
Ronald Houchin
Concerns: 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.
Overdue
John Preece
Concerns: 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.
Response: • A bespoke falls training programme, including neuro observations, has been developed and delivered to approximately 75% of relevant nurses, with arrangements in place for the remaining staff. • A … (AI summary)
Response (NMC): • The NMC confirmed that its new education and proficiency standards, effective since January 2019, ensure nurses are trained in managing falls and conducting neurological observations. • The NMC stated … (AI summary)
Responded
Jean Cutler
Concerns: 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.
Response (Cole Valley Nursing Home): • The previous manager was removed, and a consultant advisor was engaged to support improvements and recruit a new permanent manager. • New comprehensive Falls Risk Assessments (FRAs) for all … (AI summary)
Responded
Brenda Gowan
Concerns: 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.
Response (Barts Health NHS Trust): • The Trust reviewed communication and documentation for Family Care Planning Meetings, implementing reformatted documentation for signed understanding and accountability. • New Care Planning documentation will address risks, equipment, training, … (AI summary)
Responded
Emma Butler
Concerns: The coroner noted insufficient monitoring of plastic cutlery on the ward, which was used for self-harm, and inadequate searching processes for patients returning from unescorted leave, allowing self-harm materials to be brought in. Concerns were also raised about significant variations in the conduct and recording of hourly observations.
Response (Oxford Health NHS Trust): • The Trust is considering replacing plastic spoons with a more breakage-resistant alternative and will update policies on patient searching and observations. • Leave documentation and welcome packs will be … (AI summary)
Responded
Graham Jones
Concerns: 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.
Response (Gloucestershire Hospitals NHS Trust): • The Trust has implemented a Quality Improvement project to reduce falls risk, which includes a new Safety Hour Checklist for recording and transferring falls risks between wards. • The … (AI summary)
Responded
James Delaney
Concerns: The coroner noted staff lacked dedicated time for regular policy refreshers after initial training. Additionally, inconsistent medication policies across care homes regarding when to call a GP for refused doses could cause confusion, especially for transferring staff.
Response (Crystal Care Norfok Limited): • The company introduced a procedure requiring staff to re-read policies every six months, with allocated time and manager verification. • The company-wide medication policy was amended to provide specific … (AI summary)
Overdue
Edna Evans
Concerns: 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.
Overdue
Robert Lowe
Concerns: The coroner identified that pressure mats intended to detect residents leaving beds might be bypassed, and audible alarms may not be heard by staff due to their use and operation, especially when multiple alerts are active.
Overdue
Andrew Hogg
Concerns: 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.
Response (Borough Care Ltd): • Home managers will implement weekly reviews of falls using the Person Centered Software system, documenting actions in falls logs and resident support plans. • The organisation will arrange a … (AI summary)
Responded
Evelyn Ross
Concerns: 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.
Response (Manchester University NHS Foundation Trust): • The Trust recruited additional registered nurses and appointed a new Ward Manager and experienced Band 6 Registered Nurses to Ward 6, confirming the ward is now fully recruited for … (AI summary)
Response (Department of Health and Social Care): • The government committed to delivering 50,000 more nurses in the NHS by 2025 and announced financial support grants for eligible students. • The NHS Long Term Plan commits £4.5 … (AI summary)
Responded
William McKibbin
Concerns: The coroner identified insufficient 'tick-box' checks for bed safety in nursing documentation, alongside a lack of guidance for clinical incident investigations. Concerns also included a lack of organisational candour and gaps in inter-hospital information sharing.
Response (NHS England): • NHS England and NHS Improvement is promoting and encouraging NHS employers to complete free online Just and Learning Culture training. • NHS England and NHS Improvement is promoting and … (AI summary)
Response (Manchester University NHS Foundation Trust): • The Trust updated its Falls Investigation Template, Falls Policy, and Intentional Rounding documentation to include additional safety checks for bed brakes and bed rails. • A "First Responder" document … (AI summary)
Response (CQC): • The CQC stated its preference to continue receiving death notifications via the National Reporting and Learning System (NRLS) and Strategic Executive Information System (STEIS), noting that a separate reporting … (AI summary)
Response (Dept. of Health and Social Care): • The Manchester University NHS Foundation Trust apologised for failings in care and the investigation, and stated it had taken significant learning from its reflections. • The Trust confirmed it … (AI summary)
Responded
Alan Jones
Concerns: 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.
Response (Aneurin Bevan University Health Board): • The Health Board completed revisions to its Falls Policy for Hospital Adult Inpatients and developed an action plan for reducing inpatient falls, with work underway on 'Falls Prevention Collaboratives'. … (AI summary)
Responded
Select committee recommendations(2)
#7 —
Recommendation: 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 …
Response attribution not verified
#2 —
Recommendation: NHS England is not reducing the unacceptable variation in support for people with frailty across and within Integrated Care Boards (ICBs). There is significant and unexplained regional variation between areas – 32 out of 106 local NHS areas assessed less …
Response attribution not verified
CQC inspection actions(21)
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.
Must Do
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.
Must Do
Pilgrim Hospital
The trust should ensure patients at risk of falling undergo a falls risk assessment and falls preventative actions are in place.
Should Do
Pilgrim Hospital
The trust should ensure that falls and mental health risk assessments and transfer documentation are in place for patients when they are required and that completion risk assessments and transfer documentation are audited.
Should Do
Mount Vernon Cancer Centre
The trust should ensure that falls risk assessments include a lying and standing blood pressure.
Should Do
Kettering General Hospital
The servicemust ensure patient risks are fully assessed and mitigated in a timely manner. This includes but is not limited to; tissue viability, falls and deterioration.
Must Do
Diana Princess of Wales Hospital
The service should ensure that all patients deemed to be at risk of falling have a risk assessment completed upon initial assessment.
Should Do
Windsor Dialysis Unit
Theprovidershouldensurethatconsentfortheuseoffallsalaermsareincludedwithintheconsentpolicy.Wherea patientlackscapacitytoconsent,abestinterestdecisionshouldberecorded.
Should Do
Windsor Dialysis Unit
Removealltriphazardsespeciallyontheelderlycarewards.
Should Do
Victoria Infirmary
The service should take actions to improve clinical audit outcomes for chronic obstructive pulmonary disease, stroke and inpatient falls pathways.
Should Do
Royal Shrewsbury Hospital
The trust must ensure bed rails assessments are carried out on patients who require them in line with national standards.
Must Do
West Berkshire Community Hospital
Removealltriphazardsespeciallyontheelderlycarewards.
Should Do
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.
Should Do
Foxleigh Grove Nursing Home
The registered person seeks guidance from a reputable source to ensure they have an appropriate falls pathway in place for staff to follow when a person falls.
Should Do
Darenth Grange Residential Home
The provider should ensure the circumstances of a person's falls are fully considered to prevent recurrence, and accident records are carefully checked to show all necessary assistance has been provided.
Should Do
William Harvey Hospital
The trust should ensure all risk assessments on patients are completed on admission to medical wards.
Should Do
Brook House Residential Home
Address some environmental challenges for those people at risk of falling or who rely on equipment to support their mobility.
Must Do
TerraBlu Homecare
One person had fallen and injured themselves in January 2022 and had been found by a staff member. This had not been appropriately recorded.
Should Do
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.
Should Do
Forge House Services Limited
The registered manager should review a risk assessment they had put in place for a person who was at risk of falls when using the stairs, as the risk assessment required more detailed guidance for staff to support them safely.
Should Do
Rosglen Residential Home
The provider should address the use of multiple assessment tools for the same person for the same area of risk, which produced conflicting information.
Should Do
PPO death in custody recommendations(1)
Health investigations(2)
An independent external quality assurance review (published November 2019) can … — Rec 7.
The Trust should assure itself that assessments of risks in elderly patients are completed thoroughly and accurately, incorporating all aspects of relevant medical history, and which then lead to appropriate interventions to mitigate these risks.
north_east_yorkshire
An independent external quality assurance review (published November 2019) can … — Rec 7.
The Trust should assure itself that assessments of risks in elderly patients are completed thoroughly and accurately, incorporating all aspects of relevant medical history, and which then lead to appropriate interventions to mitigate these risks.
north_east_yorkshire
Scottish Fatal Accident Inquiries(2)
Alasdair Finlay Macleod
In terms of section 26(1)(b) of the 2016 Act the court recommends that: (a) all fishermen should make themselves aware of and follow the terms of Marine Guidance Note (MGN) 588 (F) which states that “failure to ensure the provision and wearing of PFDs and/or fall restraint harnesses by all fishermen working where there is a risk of falling overboard …
Mar 2019
Scott James Rennie
In terms of section 26(1)(b) of the 2016 Act the court recommends: I. that fishermen involved in this type of scallop dredger fishing should avoid standing on the tipping door of the vessel whilst at sea to carry out repairs to dredge bags or for any other reason. A system of work should be devised to avoid the need for …
Oct 2019
PHSO casework decisions(47)
P-004715 — County Durham and Darlington NHS Foundation Trust
Ms U complained her father received inadequate assessment, leading to a preventable fall and injury, and cited delayed medication and poor communication regarding his deterioration and impending death.
NHS in England
Upheld
Jan 2026
P-004658 — An independent provider in the Hammersmith and Fulham …
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.
NHS in England
Jan 2026
P-001435 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Mr T complained the Trust failed to follow his mother's falls risk assessment, leading to a fall, hip fracture, and health deterioration. He also alleged delayed family notification and an inappropriate post-falls review.
NHS in England
Upheld
Jun 2022
P-001505 — Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Mrs H complained the Trust failed to assess her mother's fall risk, delayed informing the family about her fall, skull fracture, and end-of-life care, and staff lacked empathy.
NHS in England
Upheld
Aug 2022
P-002055 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs A complained the Trust failed to identify her mother as a falls risk and left her bed rail down, causing a fall which Mrs A believes contributed to her mother's death.
NHS in England
Jun 2023
P-002765 — Gateshead Health NHS Foundation Trust
Mrs N complained about the hospital's management of her mother's fall risk, leading to three preventable falls, and the Trust's poor investigation and complaint handling.
NHS in England
Upheld
Jul 2024
P-003086 — Chesterfield Royal Hospital NHS Foundation Trust
Staff left her father alone when at risk of falling, leading to falls and a brain bleed. His CT scan was overlooked, delaying diagnosis before his death.
NHS in England
Oct 2024
P-004640 — The Hillingdon Hospitals NHS Foundation Trust
Miss B complained about inadequate care for her mother, an unwitnessed fall, poor nursing, delayed escalation, and poor communication during admission. She also cited poor complaint handling.
NHS in England
Upheld
Jan 2026
P-001237 — The Newcastle Upon Tyne Hospitals NHS Foundation Trust
Mrs O complained she fell as an inpatient, sustaining a fractured spine that left her unable to walk and requiring care home placement.
NHS in England
Dec 2021
P-001326 — Kettering General Hospital NHS Foundation Trust
Mr M complained about negligent discharge, inadequate aftercare, diagnostic failures, and poor communication regarding his father's hospital treatment, believing it led to a brain bleed and impacted his own health.
NHS in England
Mar 2022
P-001389 — A nursing home in the Lincolnshire area
Mrs U complained the nursing home failed to safeguard her stepfather, leading to him leaving unattended twice and suffering falls, one causing a fractured hip, and inappropriately shaving his hair.
NHS in England
May 2022
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.
NHS in England
Oct 2022
P-004561 — Milton Keynes University Hospital NHS Foundation Trust
Mrs Y alleged staff at Milton Keynes University Hospital failed to provide timely pain relief and fluids, neglected hygiene, poorly managed post-surgical pain, and did not prevent falls for her mother.
NHS in England
Partly Upheld
Jan 2026
P-003817 — The Hillingdon Hospitals NHS Foundation Trust
Miss F complained her mother fell out of bed, possibly due to absent bed rails, which Miss F believes led to her mother's death. Trust responses were conflicting.
NHS in England
May 2023
P-002318 — Mersey and West Lancashire Teaching Hospitals NHS Trust
Mrs A alleged the Trust failed to prevent her mother from falling and did not manage her personal hygiene adequately, causing distress to the family.
NHS in England
Nov 2023
P-002447 — A care home in the Birmingham area
Mr O complained his mother suffered several unwitnessed falls at a care home in 2021 due to insufficient monitoring, leading to injuries and distress.
NHS in England
Feb 2024
P-002496 — Gateshead Health NHS Foundation Trust
Ms A complained the Trust did not properly assess her father’s continence and falls risk, leading to him falling and his oxygen dislodging, which she believes led to his death.
NHS in England
Upheld
Mar 2024
P-002634 — James Paget University Hospitals NHS Foundation Trust
Mrs S complained she fell in the ultrasound department due to lack of assistance and chaperone. Staff then failed to inquire about her wellbeing or examine her for the injuries sustained.
NHS in England
May 2024
P-003003 — East Sussex Healthcare NHS Trust
Miss A complained clinicians failed to act on her mother’s high risk of falls in December 2022, leading to serious injuries and her death. She also alleged documentation was falsified.
NHS in England
Sep 2024
P-003130 — University Hospitals of Derby and Burton NHS Foundation …
Mr O complained the Trust failed to diagnose a blackthorn stuck in his right wrist, delaying treatment and surgery, which led to him suffering a partial disability.
NHS in England
Upheld
Nov 2024
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.
NHS in England
Not Upheld
Nov 2024
P-003173 — Northumbria Healthcare NHS Foundation Trust
Mrs E complained her mother fell from a hospital bed, breaking a rib, and the Trust failed to inform her, leading to ongoing care needs and financial impact.
NHS in England
Nov 2024
P-003254 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Mrs A complained about inadequate falls risk assessment, poor post-fall care, improper information sharing, and inappropriate transfer by two NHS Trusts, leading to a broken hip.
NHS in England
Dec 2024
P-003305 — Manchester University NHS Foundation Trust
Mrs E complained staff allowed her husband to fall by letting him go to the bathroom alone, leading to his death. She also alleged poor communication about his fall and deterioration.
NHS in England
Jan 2025
P-003370 — University Hospital Southampton NHS Foundation Trust
Mr R complained his father suffered a fall and head injury due to lack of supervision while using a commode, causing Mr R significant distress and worry about his father's safety.
NHS in England
Partly Upheld
Feb 2025
P-003647 — University Hospitals Dorset NHS Foundation Trust
Miss T complained the Trust failed to conduct a falls risk assessment or lower bed rails for her godfather, resulting in a fall that she believes contributed to his death.
NHS in England
Partly Upheld
Jun 2025
P-003933 — Cambridgeshire and Peterborough NHS Foundation Trust
Miss D complained about her father's care by two Trusts, alleging multiple falls, contracting COVID, inappropriate medication, poor nutrition support, inappropriate restraint, lack of dignity, and issues with transfer and medication.
NHS in England
Upheld
Sep 2025
P-001074 — Harrogate and District NHS Foundation Trust
Mrs A complained about her father's care, including late Parkinson's medication, several falls (one causing a fractured hip), severe pressure ulcers, and the Trust's inadequate investigation of these incidents.
NHS in England
Partly Upheld
Jun 2021
P-002525 — London North West University Healthcare NHS Trust
Mrs A complained the Trust failed to diagnose her husband's neck fractures, complete a falls assessment, and discharged him incorrectly, which she felt shortened his life.
NHS in England
Not Upheld
Mar 2024
P-002625 — Calderdale and Huddersfield NHS Foundation Trust
Miss L complained about delays in investigating her mother's liver cirrhosis and gastroscopy, a fall due to unraised bedrails, discharge without catheter care referral, and restricted family visiting.
NHS in England
Partly Upheld
May 2024
P-003062 — Chelsea and Westminster Hospital NHS Foundation Trust
Mrs U complained about her uncle's inappropriate discharge, incorrect falls risk assessment, lack of a Zimmer frame, and inaccurate information about his mobility, leading to readmission.
NHS in England
Upheld
Oct 2024
P-003063 — Cambridge University Hospitals NHS Foundation Trust
Mrs T complained her mother fell, was inappropriately discharged with COVID-19, and was transferred to a distant care home without proper communication, causing rapid deterioration and distress.
NHS in England
Oct 2024
P-003255 — Mid and South Essex NHS Foundation Trust
Mr O complained the Trust failed to prevent his fall, delayed rehabilitation, treated him for incorrect blood pressure, didn't inform other departments, and provided inaccurate records.
NHS in England
Dec 2024
P-003359 — University Hospitals Birmingham NHS Foundation Trust
Dr Y complained about numerous care failings for Mr Z, including medication overdose, inappropriate ward moves, neglected personal care, delayed tests, and racial abuse, leading to his death.
NHS in England
Feb 2025
P-003655 — A practice in the County Durham area
Mrs R complained two hospitals failed to investigate her mother's symptoms, manage nutrition, provide timely medication, or communicate effectively, contributing to her mother's death.
NHS in England
Not Upheld
Jun 2025
P-003675 — East Lancashire Hospitals NHS Trust
Miss C complained the Trust failed to prevent her mother’s fall, properly investigate injuries, maintain hygiene, account for family wishes in a DNACPR, and that records were missing or altered.
NHS in England
Not Upheld
Jul 2025
P-004243 — The Queen Elizabeth Hospital King's Lynn NHS Foundation …
Mrs B complained her father's care was poor, citing delayed doctor review after a fall, neglected catheterisation, and slow medical intervention, contributing to his death.
NHS in England
Partly Upheld
Oct 2025
P-004322 — University Hospitals Birmingham NHS Foundation Trust
Mr B complained the Trust failed in falls management, leading to his father's fall and potential stroke, left a sedative in his mouth, and imposed restrictions without proper assessments.
NHS in England
Nov 2025
P-004487 — University Hospitals Sussex NHS Foundation Trust
Mr Y complained his mother was left unattended, leading to a fall and subsequent death. He also criticised the Trust's investigation for inconsistencies and downplaying the incident.
NHS in England
Dec 2025
P-001383 — North Middlesex University Hospital NHS Trust
Daughter complained the Trust failed to investigate her father's discomfort after a fall, discharged him too soon, and questioned a Deprivation of Liberty Safeguard.
NHS in England
Feb 2022
P-001345 — University Hospitals of North Midlands NHS Trust
Mrs R complained the Trust started knee surgery too soon, ignored signs of wound infection, discharged her without antibiotics, and incorrectly placed her on a stroke ward.
NHS in England
Mar 2022
P-002017 — University Hospitals Birmingham NHS Foundation Trust
Mrs K complained about inadequate non-surgical treatment for wrist fractures, premature cast removal, ineffective physiotherapy, and incorrect recording of her fall details.
NHS in England
Partly Upheld
Jun 2023
P-002025 — A practice in the Barnet area
Mrs H complained the Practice overprescribed blood pressure medication without review, refused cardiac monitoring, and failed to provide a fitness to work certificate, leading to her collapse.
NHS in England
Jun 2023
P-003774 — Croydon Health Services NHS Trust
Mrs J complained the Trust discharged her sister-in-law without a care package or involving relatives, forcing her to pay for private care after breaking her arm.
NHS in England
Aug 2025
P-003776 — Mid Yorkshire Teaching NHS Trust
Mrs A complained her husband's sepsis antibiotics and leg ulcer debridement were delayed, and staff failed to prevent a fall. She alleged a missed opportunity for sepsis treatment.
NHS in England
Partly Upheld
Aug 2025
P-001673 — University Hospitals of Derby and Burton NHS Foundation …
The Trust allegedly provided inappropriate care for Mr R after a fall, including failures in care planning, scans, mobility management, pain control, and diagnosis, leading to pressure sores.
NHS in England
Dec 2022
P-002026 — North West Ambulance Service NHS Trust
Paramedics failed to properly assess his father after a fall, focusing on opioid use and missing potential neck/back fractures, limiting treatment options.
NHS in England
Not Upheld
Jun 2023
LGO / SPSO decisions(7)
NIPSO-18500 — Belfast Health and Social Care Trust
The Ombudsman has upheld elements of a complaint that appropriate steps were not taken to prevent an elderly patient from falling out of a hospital bed, but did not establish a link between her fall and her death the following day.
NIPSO (NI Public Service…
Health & Social Care
Jul 2020
NIPSO-201916181 — Belfast Health and Social Care Trust
We investigated an incident in which a woman suffered a fractured vertebrae after a fall in hospital. We found that the Belfast Trust failed to prepare a proper falls assessment for the patient, and failed to fully investigate how the fall happened.
NIPSO (NI Public Service…
Health & Social Care
Jul 2022
25-000-452 — Berkley Care Blenheim Limited
Summary: There was fault in the quality of care provided to Mr X’s late grandfather Mr Y by the care home. It failed to carry out a thorough pre-assessment, delayed taking action when Mr Y’s food and fluid intake reduced and failed to properly assess and respond to Mr Y’s …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
21-003-630 — City of York Council
Summary: Mrs X, who is visually impaired and unsteady on her feet, complained that the Council has failed repeatedly, to assist, as agreed, with her bin collections. She says this causes her an injustice because she is unable to collect her bins by herself and has had falls in the …
LGO (Local Government & …
Environment And Regulation
Upheld
Jan 2022
21-018-870 — West Berkshire Council
Summary: We will not investigate this complaint about the Council not allowing the installation of slip resistant flooring to the general areas of Miss X’s property as part of her disabled facilities grant works. This is because an investigation would not lead to a different outcome.
LGO (Local Government & …
Adult Care Services
Sep 2022
24-017-469 — London Borough of Redbridge
Summary: Mr X complained the Council delayed completing an Occupational Therapy (OT) assessment required for his Disabled Facilities Grant (DFG) application to carry out adaptations to his house. Mr X says this has delayed the adaptations and put him at a risk of harm as his house does not meet …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
20-005-443 — Staffordshire County Council
Summary: the complainant, Mrs X, complained the Council failed to properly consider adaptations for her family when it could not find her a four-bedroom home. The Council says it has offered suitable solutions which the family refused and could do no more when the family withdrew permission to engage with …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
Domestic Homicide Reviews(5)
Herefordshire — recommendation CCG6
The Map of Medicine care pathway for falls should be reviewed to include alcohol misuse
Herefordshire ICB
NHS Herefordshire and Worcestershire …
Tendring — recommendation 6
All staff are to be reminded to make the appropriate falls referrals through the Single Point of Contact referral pathway only with the patients agreed consent.
East of England Ambulance NHS Trust
East of England Ambulance …
Tendring — recommendation 1
The Falls prevention service should put in place a clear procedure surrounding the case management of individuals regarding their care and support needs. Trigger points to be identified within the care plan, appropriate to the individuals needs to include liaison to take place with identified carers and family members.
Anglian Community Enterprise
Anglian Community Enterprise
Dudley — recommendation 6
Dudley Domestic Abuse Local Partnership Board to recommend to Dudley Falls Prevention Partnership that a domestic abuse focussed review of its policies and procedures is undertaken to ensure (a) that routine enquiry on domestic abuse is systematically included in assessments pre and post discharge after there has been an injury …
Dudley Domestic Abuse Local Partnership Board …
Norfolk — recommendation IMR_NFR_7
Include in the guidance for staff the expected actions following a service user’s fall.
Norfolk First Response
Norfolk County Council
CQC enforcement actions(3)
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 …
Jul 2021
Criminal Prosecution: United Lincolnshire Hospitals NHS Trust
The trust pleaded guilty to failing to provide safe care and treatment to Iris Longmate, an elderly patient who fell from a commode while unsupervised and sustained burns against exposed heating pipes. Ordered to pay £111,204 in total.
Mar 2022
£100000
Warning Notice: Cambridgeshire and Peterborough NHS Foundation Trust
Warning notice served following an inspection of wards for older people with mental health problems on 28–29 January 2026. CQC found leaders had missed some concerning gaps in people’s safety. Two patients sustained unreported broken bones from unwitnessed injuries; safeguarding …
Fulbourn Hospital and the Cavell Centre
Mar 2026