During the course of the investigation it became apparent that although Mrs Roberts had been assessed upon her admission to the residential home, there had not been a referral to her GP (as would be normal practice at this home) for a further falls risk assessment: This is despite an acknowiedgement that her condition was declining prior to the first fall. Furthermore her care plan and falls risk had not been reassessed and updated prior to her return to the home from hospital after the first fall and she sustained her second fracture only two days later. An inadequate assessment of the mobility of Mrs Roberts was made and feel it is necessary to this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death and bring