Gladys Rich

1. 1. failure to identify falls risk

   “Failure to identify Mrs [name redacted] as a falls risk during a pre‐assessment process, despite the fact that she had sustained a fall requiring hospitalisation 9 months before. The pre‐assessment check may not therefore be sufficiently robust.”

2. 2. arbitrary referral policy

   “The policy of waiting for 3 falls before making a referral seems to be arbitrary and also at odds with the Fall Prevention Service requirement of 1 fall within a 12 month period before a referral will be accepted.”

3. 3. inadequate action plan handling

   “Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile.”

4. 4. missing equipment

   “The care home may not have some of the equipment that they require for patients such as Mrs [name redacted] e.g. a bed sensor mat.”

5. 5. lack of proactive follow‑up

   “Despite Mrs [name redacted] having been referred to the Falls Prevention Service by her GP and the service being notified of a fall related hospitalisation in August 2016, the onus was placed on the patient and her family to make a further appointment. In the absence of any further contact, the service assumes that their input is no longer required.”

6. 6. absence of delivery mechanism

   “There does not seem to be any mechanism for ensuring that Falls Prevention Service input is in fact delivered when it is required and that a patient is only ever discharged when it is clear that the underlying symptoms causing the falls are resolved or that measures have been put in place to mitigate the falls risk.”

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