Falls prevention plans
Lack of consistent and clear falls prevention plans in care settings, leading to varied and ineffective approaches to resident safety.
166 items
6 sources
1 inquiry
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
89match
Gladys Rich
The care home failed in fall risk assessment and action plan implementation, while the under-resourced Falls Prevention Service lacked proactive follow-up and discharge mechanisms.
Matched on
terms: fall, plan, prevention
PFD report
85match
Margaret Tuck
Multiple failures included an absent falls prevention care plan, incomplete post-fall observations, confusion over nurse responsibility, and delayed investigation of confusion, contributing to undetected deterioration.
Matched on
terms: fall, plan, prevention
PFD report
81match
Brenda Gowan
Inadequate discharge planning for a stroke patient included insufficient social care, disregarded family concerns, unassessed falls risk, lack of community support, and unprovided essential safety equipment.
Matched on
terms: fall, plan
PFD report
77match
Robert Payne
Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward transfer lacked documentation, and the fatal fall was unwitnessed.
Matched on
terms: fall, prevention
PFD report
77match
James Vinson
The deceased was not under required close supervision despite a falls risk assessment, and plans for implementing an Enhanced Care/Observation Standard Operating Procedure remain unclear.
Matched on
terms: fall, plan
PFD report
73match
Patricia Webb
Inadequate fall prevention measures included insufficient observations, failure to identify fall patterns, and a lack of recorded meaningful activities. Unsuitable non-slip footwear also posed a risk.
Matched on
terms: fall, prevention
PFD report
73match
James Harris
Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a fall, compounded by poor record-keeping and an absent registered manager.
Matched on
terms: fall, plan
PFD report
73match
Kenneth Cottam
The court was not reassured that there are clear and robust policies and procedures in place in relation to falls prevention and falls management, or that staff understood the falls policies and procedures.
Matched on
terms: fall, prevention
PFD report
73match
Beryl Walsh
There were multiple missed opportunities to identify the deceased as a high falls risk, escalate care to the falls team, or implement falls prevention equipment and assessments.
Matched on
terms: fall, prevention
PFD report
73match
Jean Cutler
The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and an inadequate post-incident investigation with unaddressed systemic issues and incomplete risk assessments.
Matched on
terms: fall, prevention
PFD report
73match
Graham Jones
Concerns include insufficient falls prevention measures, inadequate understanding of post-fall protocols and medication review, and poor handover of patient safety information between wards.
Matched on
terms: fall, prevention
PFD report
69match
Harold Wonfor
Multiple deaths occurred on a ward due to inadequate, incomplete, and unenforced falls risk assessments. Policies for vulnerable patients and the monitoring of falls prevention procedures were insufficient.
Matched on
terms: fall, prevention
PFD report
69match
Alan Jones
The patient's level of confusion and agitation increased without a multidisciplinary approach to management, and despite being in the highest falls risk category, there was a failure in falls prevention strategy; inadequate supervision contributed to multiple falls, and the ward caring for high-risk patients was staffed at a minimum level without accounting for fluctuations in acuity.
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
John William Tugwell
The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite the clear potential for serious injury.
Matched on
terms: fall
PFD report
65match
Nellie Travis
The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need for a more objective assessment method.
Matched on
terms: fall
PFD report
65match
Thomas Maher
Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient care and safety.
Matched on
terms: fall
PFD report
65match
Christine Street
Incomplete documentation and a care assistant's failure to adhere to observation policy for a vulnerable patient led to an unwitnessed fall. There was also a complete lack of documentation for specialling observations, contravening Trust and national policies.
Matched on
terms: fall
PFD report
65match
Francis Langley
Inconsistent and contradictory falls risk assessments, differing between hospital departments, failed to properly assess the patient's risk, leading to bed rails not being used despite immobility and involuntary movements.
Matched on
terms: fall
PFD report
65match
Kathleen Devine
A high-risk falls resident sustained injuries due to an unplugged falls mat, unrecorded observations, and inadequate handover information for agency staff regarding critical safety measures.
Matched on
terms: fall
PFD report
65match
Edna Evans
The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a policy for reassessment following multiple falls.
Matched on
terms: fall
PFD report
65match
Robert Lowe
Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.
Matched on
terms: fall
PFD report
65match
Andrew Hogg
A care home failed to adequately assess and manage escalating falls risks, lacking a comprehensive falls policy, proper risk reassessments, internal investigations, and proactive measures or equipment to prevent repeated incidents.
Matched on
terms: fall
PFD report
65match
Evelyn Ross
The ward suffered from long-term understaffing, reliance on agency staff, and delays in discharge due to lack of community care. Poor documentation, failure to follow falls policy, and insufficient consultant reviews also meant deterioration went unescalated.
Matched on
terms: fall
PFD report
61match
May Gibson
The report identifies failures in obtaining and accounting for a community care assessment, performing pre-assessments, developing adequate care plans, conducting risk assessments, and implementing risk reduction plans at the care home.
Matched on
terms: plan
PFD report
61match
Ethel Cross
Wheeled chairs accessible to elderly patients caused falls, and a shortage of alarms for high-risk patients meant they could mobilize unsupported.
Matched on
terms: fall
PFD report
61match
William Beckwith
A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, home environment, or essential post-discharge care needs.
Matched on
terms: fall
PFD report
61match
Edna Bulmer
The coroner noted inconsistencies in the documented level of falls risk and that measures to minimise risk were not implemented promptly. It was also unclear whether a system was in place for reviewing risk assessments after further incidents.
Matched on
terms: fall
PFD report
61match
Thomas Taylor
The falls risk assessment policy fails to presume increased risk for certain patient classes, like stroke patients, potentially leading to misclassification and adverse outcomes. Individual assessment without this presumption is questioned.
Matched on
terms: fall
PFD report
61match
Emmeline Hampson
Inadequate review of falls risk assessments after repeated falls and patient condition changes was noted. Poor documentation, an insufficient alarm system, and a lack of agency staff training were also concerns.
Matched on
terms: fall
PFD report
61match
Howell Fisher
Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk assessment and handover information between hospitals.
Matched on
terms: fall
PFD report
61match
Vincent Smith
The nursing home failed to adequately assess and act upon a resident's vulnerability to falls. Concerns were raised regarding the admissions policy, falls risk assessments, and associated staff training.
Matched on
terms: fall
PFD report
61match
Milly Zemmel
There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing over critical patient information, leading to an unsupervised, vulnerable patient falling. The internal investigation was also inadequate.
Matched on
terms: fall
PFD report
61match
Freda Cordy
A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific falls risk assessment despite a history of falls, and inadequate preventative equipment.
Matched on
terms: fall
PFD report
61match
Roger Tombs
Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of undetected falls, injury, and death for vulnerable residents.
Matched on
terms: fall
PFD report
61match
Ivy Mitchell
Inaccurate falls risk documentation, poor staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes jeopardised patient safety.
Matched on
terms: fall
PFD report
61match
Ida Toole
A high falls risk patient was denied a sensor mat based on mental capacity, demonstrating a policy requiring urgent review for potentially neglecting safety needs.
Matched on
terms: fall
PFD report
61match
Peter King
Multiple deaths resulted from inadequate, incomplete, or unenforced falls risk assessments on the ward, including poor documentation, lack of intervention, and failure to address risks at handover.
Matched on
terms: fall
PFD report
61match
Ronald Houchin
Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable falls for the patient.
Matched on
terms: fall
PFD report
61match
John Preece
Significant failures in falls management, head injury recognition, and neuro observation training among staff, compounded by a lack of appropriate monitoring and early warning systems for mentally unwell patients.
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-004561 - Milton Keynes University Hospital NHS Foundation Trust
Mrs Y complains about the care and treatment her mother, Mrs D, received from Milton Keynes University Hospital NHS Foundation Trust between May and July 2023. She raises concerns about delays in pain relief and fluids, poor hygiene practices, inadequate post-surgery pain management, failures in fall prevention, and rough handling by staff, all of which impacted her mother’s...
Matched on
terms: fall, prevention
PFD report
57match
Laura Hill
Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and ward transfer.
Matched on
terms: fall
PFD report
57match
James McArdle
The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the risk of falls for elderly patients.
Matched on
terms: fall
PFD report
57match
Hilda Thompson
There was a significant failure in falls risk assessment upon admission, with no further review for 10 days, leaving the patient vulnerable. This oversight was exacerbated by poor note-taking.
Matched on
terms: fall
PFD report
57match
Martin McCabe
The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated assessment and omitting crucial new information about recent falls and sedative use.
Matched on
terms: fall
PFD report
57match
Jeanne Summers
Inadequate discharge assessment, incomplete physiotherapy records, and unsafe patient mobilization practices, including inappropriate footwear and unsupervised transfers, contributed to a fall. The subsequent investigation was also found to be insufficient.
Matched on
terms: fall
PFD report
57match
Kenneth Swift
An elderly patient at high risk of falls was not provided with an essential falls sensor due to equipment shortages and a long waiting list, despite the known risks.
Matched on
terms: fall
PFD report
57match
Henry Honour
Multiple deaths on a ward were linked to inadequate or unenforced falls risk assessments. Specific to this case, the assessment was perfunctory, bed rails were misused, and no protective measures were implemented post-fall.
Matched on
terms: fall
PFD report
57match
James Delaney
Care home staff lacked regular refresher training on policies and procedures. Inconsistent policies regarding medication refusal across different homes created confusion and potential risks.
Matched on
classifier match