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
Source spread
Where this theme appears
Falls prevention plans has been flagged across 6 independent accountability sources:
1 inquiry rec
101 PFD reports
8 CQC actions
1 PPO rec
48 PHSO decisions
7 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
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.
PFD Reports (101) — showing 50 strongest matches
May Gibson
Concerns: 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.
Overdue
Ethel Cross
Concerns: Wheeled chairs accessible to elderly patients caused falls, and a shortage of alarms for high-risk patients meant they could mobilize unsupported.
Overdue
Laura Hill
Concerns: Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and ward transfer.
Response (Stockport NHS Foundation Trust): Stockport NHS Foundation Trust has instigated an escalation process for locating equipment, to be monitored via the Datix system. The nurses involved were formally counselled, and the case was presented …
Responded
John William Tugwell
Concerns: 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.
Overdue
Nellie Travis
Concerns: 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.
Overdue
Thomas Maher
Concerns: 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.
Response (Central Manchester University Hospital NHS Trust): The hospital has implemented a new process to scan all records for deceased patients and those involved in high-level incidents into the electronic patient records system as a priority. Ward …
Responded
James McArdle
Concerns: The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the risk of falls for elderly patients.
Response (Wirral University Teaching Hospitals NHS Foundation Trust): The Trust is developing a new policy specific to patient falls, providing clearer guidance on risk assessments and timescales, and will communicate changes to nursing staff and revise audit questionnaires …
Responded
William Beckwith
Concerns: 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.
Response: The hospital is undertaking a multidisciplinary review of its guidance for assessing elderly patients after a fall, with a clear policy expected by the end of August.
Responded
Ian Reid
Response (Department of Health): NHS England has established a reference group to develop standards for prosthesis identification, including details of all prosthesis use in the patient record, with a target completion date of early …
Responded
Edna Bulmer
Concerns: 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.
Overdue
Hilda Thompson
Concerns: 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.
Overdue
Martin McCabe
Concerns: 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.
Overdue
Thomas Taylor
Concerns: 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.
Overdue
Emmeline Hampson
Concerns: 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.
Overdue
Jeanne Summers
Concerns: 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.
Overdue
Robert Payne
Concerns: 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.
Overdue
Howell Fisher
Concerns: 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.
Overdue
Vincent Smith
Concerns: 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.
Overdue
Milly Zemmel
Concerns: 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.
Response (Response Pennine Acute Hospitals): The Trust has revised its Incident Reporting and Investigation Policy, launched an Enhanced Patient Observation Policy, and will include failure to escalate lack of medical review in the Lessons Learned …
Responded
Christine Street
Concerns: 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.
Response (Brighton and Sussex University Hospitals NHS Trust): Brighton and Sussex University Hospitals NHS Trust held study days for nurses on LBAW covering topics including Deprivation of Liberty, falls prevention, one-to-one care, and end of life care, after …
Responded
Freda Cordy
Concerns: 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.
Overdue
Margaret Tuck
Concerns: 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.
Response (Barths Health NHS Trust): Barts Health NHS Trust has re-instructed staff on falls risk assessments and care plans, clarified nursing responsibilities, reinforced post-falls procedures, and implemented measures to improve communication between medical teams. They …
Responded
Roger Tombs
Concerns: 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.
Response (Sunrise Senior Living): Sunrise Senior Living acknowledges the report but states it is leaving the Home's management and registration with CQC on 1 March 2017. It invites dialogue and can describe immediate actions …
Response (Roger Tombs): The Falls Team reviewed its practices after the PFD report and found them consistent and accurate. A guidance document outlining good practice in sensor mat use was developed and sent …
Overdue
Patricia Webb
Concerns: 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.
Overdue
Ivy Mitchell
Concerns: Inaccurate falls risk documentation, poor staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes jeopardised patient safety.
Response (Fairfield View Care Centre): The care centre audited all documentation regarding falls and mobility, cascaded information to staff about completing relevant documentation, and is auditing care plans and daily records. Senior staff are undertaking …
Overdue
Ida Toole
Concerns: 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.
Overdue
Francis Langley
Concerns: 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.
Response (Great Western Hospital NHS Trust): The Trust has implemented the nursing personalised care plan documentation used at GWH on Forest and Orchard wards (SWICC) from July 2017, which includes bed rails assessment, falls assessment and …
Responded
Kenneth Swift
Concerns: 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.
Response (York Teaching Hospital NHS Trust): The Trust has implemented a process of escalation to Matron/Patient Safety Team when sensor requests cannot be achieved, agreed a new management system with the Equipment Library, introduced additional training …
Responded
James Harris
Concerns: 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.
Response (Care First Class UK): Care First Class UK has implemented read and sign sheets for care plans, provided a falls protocol to all staff, maintained records of nightly checks, and addressed pain management procedures; …
Response (CQC): CQC acknowledges the concerns raised regarding Cherry Lodge Care Home, details actions taken by the provider, and explains its regulatory role and monitoring of the situation, including the need for …
Responded
James Vinson
Concerns: 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.
Response (City Hospitals Sunderland NHS Trust): The Trust is piloting an Enhanced Care Standard Operating Procedure (SOP) with an Enhanced Care Risk Assessment Tool and criteria for observation levels, with a target ratification date of January …
Responded
Kenneth Cottam
Concerns: 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.
Response (Coxbench Hall Residentail Home): Coxbench Hall Residential Home asserts that they have clear and robust policies and procedures in place in relation to falls risk assessment and management, including a policy checklist for staff, …
Responded
Harold Wonfor
Concerns: 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.
Response (Response East Kent NHS Trust): The Trust monitors patient falls monthly as part of its quality indicators and has introduced SafeCare to enable ward staff to see if their staffing levels match demand; a full …
Responded
Kathleen Devine
Concerns: 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.
Response (Bloom Care): The care home has implemented several changes including creating care plans for residents with crash/sensor mats, adding information to handover sheets, adding an extra column on mattress check sheets, updated …
Overdue
Henry Honour
Concerns: 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.
Overdue
Peter King
Concerns: 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.
Response (East Kent NHS Trust): The Trust monitors patient falls monthly as part of its quality indicators and has introduced SafeCare to enable ward staff to see if their staffing levels match demand; a full …
Responded
Gladys Rich
Concerns: 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.
Response (Avenue House Care Home): The care home will contact the Falls Team after sending referrals and action plans to confirm receipt and intended actions, recording all contact in residents' care plans.
Overdue
Beryl Walsh
Concerns: 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.
Response (Beechwood Lodge): Beechwood Lodge has put in place more robust risk assessments for residents who have had falls, documenting all conversations with relatives and professionals. They have added new risk assessments in …
Responded
Ronald Houchin
Concerns: Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable falls for the patient.
Overdue
John Preece
Concerns: 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.
Response: The Health Board has implemented a falls training program developed by Practice Nurse Educators, introduced an escalation policy specifically for St Barruc ward, and uses NEWS across MHSOP wards in …
Response (NMC): The NMC outlines its regulatory role in setting and maintaining standards for registered nurses and refers to new standards and assurance processes to ensure nurses entering the register are properly …
Responded
Jean Cutler
Concerns: 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.
Response (Cole Valley Nursing Home): New, comprehensive Falls Risk Assessments (FRAs) for all residents have been introduced and completed, considering internal and external risk factors. A new competent, experienced and dynamic manager who will provide …
Responded
Brenda Gowan
Concerns: 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.
Response (Barts Health NHS Trust): The Trust will document care planning meetings, offer experiential training for carers including an overnight stay, and include carer guidelines in the discharge information. These changes will be reviewed within …
Responded
Emma Butler
Concerns: Inadequate control of plastic cutlery on the ward and inconsistent search procedures for patients returning from leave created self-harm risks, compounded by variable hourly observation practices.
Response (Oxford Health NHS Trust): The Trust has already implemented measures like case discussion groups and reflective practice groups run by psychotherapists. They also have MDT handovers every morning and provide more access to psychological …
Responded
Graham Jones
Concerns: Concerns include insufficient falls prevention measures, inadequate understanding of post-fall protocols and medication review, and poor handover of patient safety information between wards.
Response (Gloucestershire Hospitals NHS Trust): The Trust has implemented several measures, including local ward training on falls prevention, the Silver QI project to improve staff awareness of falls prevention, enhanced identity verification procedures in radiology, …
Responded
James Delaney
Concerns: Care home staff lacked regular refresher training on policies and procedures. Inconsistent policies regarding medication refusal across different homes created confusion and potential risks.
Response (Crystal Care Norfok Limited): The Company have introduced a procedure by which staff are required to re-read policies six months of their employment. The Company have now created a checklist for staff who are …
Overdue
Edna Evans
Concerns: 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.
Overdue
Robert Lowe
Concerns: Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.
Overdue
Andrew Hogg
Concerns: 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.
Response (Borough Care Ltd): • All home managers will review falls on the Person Centered Software (PCS) system weekly and add notes regarding actions taken to the falls log and residents' support plans. • …
Responded
Evelyn Ross
Concerns: 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.
Response (Manchester University NHS Foundation Trust): The Trust states that regular consultant reviews did occur and there were no issues with junior doctor escalation in the case of Mrs Ross. The Trust also outlines measures in …
Response (Department of Health and Social Care): The response acknowledges the concerns raised and refers to the Trust's detailed response. It then outlines national-level actions related to nursing workforce, falls prevention, and delayed transfers of care, referencing …
Responded
William McKibbin
Concerns: Delayed diagnosis prolonged hospitalisation, and a fatal fall was caused by nursing staff failing to secure bed rails and brakes during a patient's stay.
Response (NHS England): NHS England notes the Trust's response and states it is promoting the free online Just and Learning Culture training to NHS employers.
Response (Manchester University NHS Foundation Trust): The Trust acknowledges failings in care and communication and has implemented several changes, including red flag identification, a revised Serious Incident Panel process for 12 months, and a local Serious …
Response (CQC): The CQC acknowledges the concerns and explains the statutory notification process. While stating that current reporting processes are adequate, it will review existing notifications guidance to determine if it could …
Response (Dept. of Health and Social Care): The Trust has updated its falls investigation template to include more detailed guidance around immediate action, including checking and documenting the environment of a fall. The CQC will review its …
Responded
Alan Jones
Concerns: 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.
Response (Aneurin Bevan University Health Board): The Health Board has reported the death to the Health & Safety Executive, developed a dashboard within the Datix Incident Reporting system for falls resulting in significant harm, and incorporated …
Responded
CQC Inspection Actions (8)
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
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
PHSO Casework Decisions (48)
P-004715 — County Durham and Darlington NHS Foundation Trust
Ms U complained about a fall her father, Mr L, sustained whilst in hospital under the care of the Trust. She complained this fall led to Mr L's death.
NHS in England
Upheld
Jan 2026
P-004658 — An independent provider in the Hammersmith and Fulham …
Mrs H complains on behalf of her late uncle about the care he received whilst a resident at a Care Home. Mrs H complains the Care Home failed to properly assess and manage her uncle's known falls risk between 23 October and 21 December 2024.
NHS in England
Jan 2026
P-001435 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Mr T raises various complaints about the care and treatment his mother, Mrs T, received at the Trust. Specifically, Mr T complains the Trust failed to follow the falls risk assessment completed for his mother, did not inform the family about her fall in a timely manner, did not send …
NHS in England
Upheld
Jun 2022
P-001505 — Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Mrs H complains that her late mother experienced an avoidable fall as part of an admission to the Trust. She also complains about the Trust’s communication with her about her mother’s deterioration, end-of-life care, and the investigation into her fall.
NHS in England
Upheld
Aug 2022
P-002055 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs A complains the Trust failed to identify her mother as at risk of falling and left the bed rail on her bed down, causing her to fall out of bed.
NHS in England
Jun 2023
P-002765 — Gateshead Health NHS Foundation Trust
Mrs N complains about how clinicians at a hospital managed her mother’s risk of falling. She is dissatisfied with how the Trust investigated her mother’s falls and responded to complaints.
NHS in England
Upheld
Jul 2024
P-003086 — Chesterfield Royal Hospital NHS Foundation Trust
Miss Y complains the Trust left her father alone twice in one day when they knew he was at risk of falling and this led to him falling twice.
NHS in England
Oct 2024
P-004640 — The Hillingdon Hospitals NHS Foundation Trust
Miss B complains about the care and treatment The Hillingdon Hospitals NHS Foundation Trust provided to her mother, Ms J, during an inpatient admission from 27 April 2020 to 4 May 2020. She specifically complains about falls assessments, nursing care, communication and complaint handling.
NHS in England
Upheld
Jan 2026
P-001237 — The Newcastle Upon Tyne Hospitals NHS Foundation Trust
Mr O complained about a fall his wife had while being assisted at the Trust.
NHS in England
Dec 2021
P-001326 — Kettering General Hospital NHS Foundation Trust
Mr M complained about the care and treatment Kettering General Hospital NHS Foundation Trust gave his father between November 2020 and January 2021. He says the Trust’s negligence led to his father having a brain bleed after a fall in hospital.
NHS in England
Mar 2022
P-001389 — A nursing home in the Lincolnshire area
Mrs U complains about the care and treatment her stepfather, Mr T, received at his nursing home from February to May 2020. Specifically, she complains he absconded several times, had several falls and fractured his femur.
NHS in England
May 2022
P-001563 — Mid and South Essex NHS Foundation Trust
Miss O complains staff working for the Trust left her father’s bed rails down, although the care plan said these should be kept up. She says because of this, her father fell from his bed and died.
NHS in England
Oct 2022
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 …
NHS in England
Partly Upheld
Jan 2026
P-003817 — The Hillingdon Hospitals NHS Foundation Trust
Miss F complains her mother fell out of bed while under the Trust's care. She says the Trust's complaint responses gave unclear information about what happened and if bed rails were in place or not.
NHS in England
May 2023
P-002318 — Mersey and West Lancashire Teaching Hospitals NHS Trust
Mrs A complains that between September and December 2022 the Trust did not prevent her mother’s falls as staff did not help her in and out of bed. She also complains it did not manage her personal hygiene and welfare to an acceptable standard.
NHS in England
Nov 2023
P-002447 — A care home in the Birmingham area
Mr O complains that staff at the care home did not properly monitor his mother when she was moving and this led to her having several unwitnessed falls.
NHS in England
Feb 2024
P-002496 — Gateshead Health NHS Foundation Trust
Ms A complains the Trust did not carry out appropriate nursing assessments of her father’s needs, failed to meet his continence needs and failed to assess his falls risk.
NHS in England
Upheld
Mar 2024
P-002634 — James Paget University Hospitals NHS Foundation Trust
Mrs S complains she fell in the Trust's ultrasound department because staff did not attend to her or help her correctly.
NHS in England
May 2024
P-003003 — East Sussex Healthcare NHS Trust
Miss A complains that clinicians failed to act on her mother’s high risk of falls in December 2022. She says her mother had two serious accidents and sustained significant injuries. Miss A also believes documentation was falsified.
NHS in England
Sep 2024
P-003130 — University Hospitals of Derby and Burton NHS Foundation …
Mr O complains about University Hospitals of Derby and Burton NHS Foundation Trust and the lack of care after falling and experiencing a wrist injury in February 2023.
NHS in England
Upheld
Nov 2024
P-003134 — University Hospitals of Liverpool Group
Mrs A complains the Trust failed to have a sufficient falls plan in place for her brother during his admission in December 2022. She also complains the Trust failed to carry out appropriate tests after he fell to establish the extent of his injuries and make sure he received appropriate …
NHS in England
Not Upheld
Nov 2024
P-003173 — Northumbria Healthcare NHS Foundation Trust
Mrs E complains her mother fell from bed while she was on the ward and that the Trust did not tell her about this.
NHS in England
Nov 2024
P-003254 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Mrs A is complaining the Trust did not appropriately manage her falls care or share information correctly. She also complains the Trust inappropriately supported her care.
NHS in England
Dec 2024
P-003305 — Manchester University NHS Foundation Trust
Mrs E complains that staff allowed her husband to go to the bathroom alone and without oxygen which resulted in him having a fall.
NHS in England
Jan 2025
P-003370 — University Hospital Southampton NHS Foundation Trust
Mr R complains about the lack of care provided to his father by University Hospital Southampton NHS Foundation Trust (the Trust), which resulted in a fall on 25 May 2023.
NHS in England
Partly Upheld
Feb 2025
P-003647 — University Hospitals Dorset NHS Foundation Trust
Miss T complains about the Trust’s actions before her godfather had a fall in hospital.
NHS in England
Partly Upheld
Jun 2025
P-003741 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs L complains the Trust cared for her on a faulty hospital bed which caused her to fall and break her hip, that it did not provide physiotherapy support and it failed to properly investigate and listen to her concerns.
NHS in England
Upheld
Aug 2025
P-003933 — Cambridgeshire and Peterborough NHS Foundation Trust
Miss D complains about the organisation's care of her father between September and December 2022. She complains about failures to prevent falls, getting COVID-19, to provide medication, nutritional support and to keep her father's dignity.
NHS in England
Upheld
Sep 2025
P-001074 — Harrogate and District NHS Foundation Trust
Mrs A complains about aspects of the care and treatment staff at the Hospital gave to her father, stating that they were late giving her father his medication for Parkinson’s disease and did not give it at all several times, which increased her father’s confusion, caused him to hallucinate and …
NHS in England
Partly Upheld
Jun 2021
P-002525 — London North West University Healthcare NHS Trust
Mrs A complains the Trust did not recognise that her husband had two fractured bones in his neck, it did not complete a falls assessment and it wrongly discharged him
NHS in England
Not Upheld
Mar 2024
P-002625 — Calderdale and Huddersfield NHS Foundation Trust
Miss L complains about the care the Trust gave to her mother between March and July 2021. She complains doctors did not fully investigate the cause of her mother’s liver cirrhosis and delayed treatment, her mother fell out of bed because bedrails were not correctly used, she was discharged without …
NHS in England
Partly Upheld
May 2024
P-003062 — Chelsea and Westminster Hospital NHS Foundation Trust
Mrs U complains the Trust discharged her uncle inappropriately and without a zimmer frame, which resulted in him being readmitted the same day. She also complains the Trust completed a falls assessment incorrectly and it provided her with inaccurate information about his mobility.
NHS in England
Upheld
Oct 2024
P-003063 — Cambridge University Hospitals NHS Foundation Trust
Mrs T complains that Cambridge University Hospitals NHS Foundation Trust failed to prevent her mother falling in hospital and incorrectly discharged her.
NHS in England
Oct 2024
P-003255 — Mid and South Essex NHS Foundation Trust
Mrs O complains about the Trust’s care of her husband in May 2023. She says his fall could have been prevented, the rehabilitation plan was delayed, he was treated for high blood pressure instead of low and the Trust did not keep departments updated about the care. She also complains …
NHS in England
Dec 2024
P-003359 — University Hospitals Birmingham NHS Foundation Trust
Dr Y complains about the care and treatment University Hospitals Birmingham NHS Foundation Trust provided to her father after he fell at home.
NHS in England
Feb 2025
P-003655 — A practice in the County Durham area
Mrs R complains about how clinicians at two different organisations cared for and treated her mother towards the end of her life. She is particularly concerned about how doctors managed a bleed on her mother’s brain and how clinicians managed her mother’s risk of falling.
NHS in England
Not Upheld
Jun 2025
P-003675 — East Lancashire Hospitals NHS Trust
Miss C complains about how clinicians at a hospital cared for and treated her mother towards the end of her life. She is particularly concerned about whether they could have prevented a fall and their response to the fall when it happened.
NHS in England
Not Upheld
Jul 2025
P-004243 — The Queen Elizabeth Hospital King's Lynn NHS Foundation …
Mrs B complains The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust delayed reviewing her father for two days following a fall, did not catheterise him when he needed this, and did not appropriately manage his condition when he started to deteriorate.
NHS in England
Partly Upheld
Oct 2025
P-004322 — University Hospitals Birmingham NHS Foundation Trust
Mr A complains the Trust's falls management was poor, and it had a poor post‑incident response after his father fell in March 2023. He also complains there was a failing in the Trust's use of sedatives and the Trust imposed restrictions on his father without proper safeguards.
NHS in England
Nov 2025
P-004487 — University Hospitals Sussex NHS Foundation Trust
Mr Y has concerns that his mother experienced a fall at the Trust and subsequently died. Mr Y was also concerned about the Patient Safety Incident Investigation
NHS in England
Dec 2025
P-001383 — North Middlesex University Hospital NHS Trust
Mrs E complains that North Middlesex University Hospital NHS Trust did not follow the correct process after her late father fell in hospital and she told us it did not put in place a Deprivation of Liberty Safeguard for him soon enough.
NHS in England
Feb 2022
P-001345 — University Hospitals of North Midlands NHS Trust
Mrs R complained about the care and treatment she received from the Trust after she fell and fractured her knee cap in a number of places.
NHS in England
Mar 2022
P-002017 — University Hospitals Birmingham NHS Foundation Trust
Mrs K complains the Trust did not do enough when she fell and fractured her wrist. She says it chose to give her conservative treatment, it took the cast off too soon and the telephone physiotherapy was not helpful.
NHS in England
Partly Upheld
Jun 2023
P-002025 — A practice in the Barnet area
Mrs H complains the Practice did not monitor her high blood pressure and medication properly and this caused her to experience dizziness and to fall. She also complains the Practice did not give her a fitness to work certificate.
NHS in England
Jun 2023
P-003774 — Croydon Health Services NHS Trust
Mrs J complains that the Trust failed to provide her sister-in-law, Mrs H, with a safe discharge, following her A&E attendance after she fell and broke her arm.
NHS in England
Aug 2025
P-003776 — Mid Yorkshire Teaching NHS Trust
Mrs A complains the Trust did not treat her husband's sepsis promptly, did not perform a surgical procedure when they should have done, and that he fell from bed.
NHS in England
Partly Upheld
Aug 2025
P-001673 — University Hospitals of Derby and Burton NHS Foundation …
Mrs V complains about the care and treatment her late father had from the Trust between September 2018 and March 2019 after he fell at home.
NHS in England
Dec 2022
P-002026 — North West Ambulance Service NHS Trust
Mr R complains the paramedics did not properly assess his father after he fell. He says they did not ask the right questions, they did not listen when he was worried his father may have fractured his neck and they did not transport him to the ambulance safely.
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