Why does post-fall care matter so much?
Falls are the most commonly reported type of patient safety incident in hospitals in England. Most cause little or no physical harm, but some lead to hip fractures, head injuries or a long period on the floor, and even a fall without injury can cause fear of falling and loss of confidence. How staff respond in the first minutes and hours can decide whether an injury is made worse or picked up in time.
NHS England has confirmed that earlier national standards for essential care after an inpatient fall remain valid. Every organisation with inpatient beds should have a post-fall protocol covering checks for fracture and spinal injury before moving, safe manual handling, neurological observations when head injury cannot be excluded, and timescales for medical examination. NICE quality standard QS86 sets out the same expectations.
What should you do immediately after a patient falls?
Your instinct may be to help the patient straight back to bed. That can cause serious harm if they have a spinal injury, a hip fracture or a head injury. Follow your organisation's post-fall protocol; the steps below show the usual order.
- Stay with the patient and call for help: Do not leave them. Reassure them, keep them warm and protect their dignity while they are on the floor.
- Check for danger, response and breathing: Make the area safe. If the patient is unresponsive or not breathing normally, start basic life support and call the emergency team.
- Check for spinal injury: Ask about neck or back pain and check for numbness, tingling or weakness in the limbs. If spinal injury is possible, or the patient cannot reliably report symptoms, do not move them; keep them still and get urgent medical review.
- Check for head injury: Ask whether they hit their head, look for wounds or bruising, check their level of consciousness and ask witnesses. If the fall was unwitnessed and the patient cannot say for certain, assume a head injury may have happened.
- Check for fractures: Look for pain, swelling, deformity, inability to bear weight, or a shortened, externally rotated leg with groin pain, which suggests a hip fracture.
- Take a full set of observations: Record observations and NEWS2 and check blood glucose, ideally while the patient is still on the floor. Infection, arrhythmia, stroke and hypoglycaemia can all present as a fall.
- Move the patient safely: If there is no suspected spinal injury or fracture and the patient is well enough, use a lifting cushion or hoist. Suspected fracture or spinal injury needs flat-lifting equipment such as a scoop and trained staff. Do not lift the patient by hand.
- Arrange medical review: Request review within the timescale your protocol sets, using the fast-track route for signs of serious injury, high vulnerability (such as anticoagulation) or if the patient was immobilised.
What if the patient takes anticoagulants or the fall was unwitnessed?
Unwitnessed falls and falls in people taking anticoagulants are where serious injuries are most often missed. An older person may not remember hitting their head, may be embarrassed, or may simply want to get back to bed.
NG232 lists features that mean an adult needs a CT head scan within 1 hour, including a GCS below 13 on first assessment, a GCS below 15 two hours after the injury, suspected open, depressed or basal skull fracture, a post-traumatic seizure, a focal neurological deficit, or more than one episode of vomiting. Check the full current list in the guideline and your local policy.
How often should neuro obs be done after a fall?
If the patient hit their head, or a head injury cannot be excluded, start neurological observations in line with your protocol and NICE NG232. These usually include GCS, pupil size and reaction, limb movements, respiratory rate, heart rate, blood pressure, temperature and saturations. Where indicated, NG232 recommends half-hourly observations until GCS 15, then half-hourly for 2 hours, hourly for 4 hours and 2-hourly after that, going back to half-hourly if the patient deteriorates. Escalate any drop in GCS, worsening headache, repeated vomiting, new weakness or pupil change immediately.
Common mistakes in post-fall care
| Mistake | Why it matters | What to do instead |
|---|---|---|
| Accepting 'I'm fine' after an unwitnessed fall | Older people and people with delirium or dementia often under-report pain or head strikes | Complete the full checks whatever the patient says, and record what you checked |
| Lifting by hand 'just this once' | It can worsen a fracture or spinal injury and injure staff | Use the lifting cushion, hoist or scoop and the staffing your policy requires |
| Waiting until morning to inform the doctor | Bleeding, fractures and acute illness become harder to treat with time | Request review within your protocol's timescale, day or night |
| One set of neuro obs, then stopping | Deterioration after head injury can be delayed for hours | Follow the full schedule and escalate any change |
| Not looking for the cause | The fall may be the first sign of infection, stroke, arrhythmia or a medicine effect | Check observations and glucose, review medicines and recent changes |
| Forgetting the 'long lie' | Time on the floor can cause pressure damage, dehydration, hypothermia and muscle breakdown | Ask how long they were down; check skin, temperature, fluids and kidney function where relevant |
Worked case: an unwitnessed fall at night
Grace, a staff nurse on an older people's ward, finds an 88-year-old woman who takes apixaban sitting beside her bed at 3 am. Nobody saw the fall. The patient says she is fine and wants to get back into bed. Grace and a healthcare assistant help her up under the arms and Grace writes 'found on floor, no injury, assisted back to bed'. No observations are taken and the doctor is not called. At 7 am the patient is drowsy and vomiting, and a CT scan shows a subdural haemorrhage.
The patient told me she was fine and didn't seem injured. It was the middle of the night and the doctor was busy, so I planned to hand over in the morning. In future I will do observations after a fall.
I found a woman on an anticoagulant on the floor after an unwitnessed fall and did not treat it as a possible head injury, even though she could not have known for certain. I lifted her manually without checking for spinal injury or fracture and without equipment. I took no observations, did not start neuro obs and did not request the medical review our protocol requires. This delayed recognition of a serious bleed by several hours. I reported the incident and was open with her family with my manager's support. I have since completed post-fall and moving and handling training, learned to use the lifting cushion, and now treat every unwitnessed fall as a possible head injury and request review at any hour. My manager has reviewed my documentation of later falls and observed my practice.
The stronger reflection names each missed step, links it to the protocol and to this patient's risk, recognises the danger of manual lifting, avoids using the night shift as an excuse, and shows specific, verified change.
How should you document and report a fall?
- Time and place of the fall, and whether it was witnessed.
- What the patient and any witnesses said happened.
- The checks done before moving, and what you found.
- How the patient was moved and with what equipment.
- Observations, NEWS2, blood glucose and any neurological observations.
- Who was informed (medical team, nurse in charge, family) and when.
- Injuries found and the plan.
- Changes made to the falls prevention plan.
Report every inpatient fall on your local incident system, whether or not there was harm. Tell the family or carers, with the patient's agreement where they have capacity. If the fall caused moderate or severe harm, your organisation's duty of candour process applies. Be honest about what happened and what is being done.
After the immediate care: why did the patient fall?
NICE NG249 (April 2025), which replaced CG161, recommends a comprehensive multifactorial falls assessment for inpatients aged 65 and over, and for those aged 50 to 64 with a condition that increases their risk. NICE advises against relying on falls risk prediction scores. Instead, find the specific factors that can be changed for each person and act on them.
| Question to ask after a fall | Possible action |
|---|---|
| Has a new medicine been started or changed, or is the patient on sedatives, antihypertensives, diuretics or opioids? | Request a medication review |
| Is there a drop in blood pressure on standing? | Measure lying and standing blood pressure properly and inform the medical team |
| Is the patient newly confused or more confused than usual? | Screen for delirium with a tool such as the 4AT and look for causes |
| Did they fall on the way to the toilet? | Toileting plan, bedside commode, review timing of diuretics |
| Were glasses, walking aid, call bell and footwear within reach? | Adjust the environment and check before leaving the bedside |
| Are bed rails appropriate? | Individual risk assessment; consider a low bed and crash mat for restless patients |
Building confidence in post-fall care
Find your organisation's post-fall protocol and check where the flat-lifting equipment and lifting cushion are kept before you need them. Practise using the equipment with your team. Review a few of your own post-fall records against the documentation list above; this also makes good evidence for revalidation. If you are involved in a serious incident and contacted by your regulator, seek advice from your defence organisation, trade union or professional body.
Our course Falls Prevention and Post-Fall Management covers multifactorial assessment, targeted interventions, the checks before moving a patient, safe lifting, neurological observations, documentation and learning from incidents, with worked examples and a guided reflection. It is written for nurses, nursing associates, physiotherapists, occupational therapists, paramedics and other professionals caring for adults at risk of falls, and complements your organisation's practical moving and handling training.
Frequently asked questions
What is the first thing to do when a patient falls?
Stay with the patient and call for help. Check the area is safe and that the patient is responsive and breathing normally; if not, start basic life support and call the emergency team. Then check for spinal injury, head injury and fractures before moving them, and take a full set of observations and blood glucose.
Should you get a patient up straight away after a fall?
No. Check first for spinal injury, fractures and head injury. If spinal injury or fracture is suspected, do not move the patient; keep them still and get urgent medical review, then use flat-lifting equipment such as a scoop with trained staff. If there is no suspected injury, use a lifting cushion or hoist rather than lifting by hand.
Do all unwitnessed falls need neuro obs?
If a head injury cannot be excluded, which is often the case after an unwitnessed fall, neurological observations should be started in line with your post-fall protocol and NICE head injury guidance. Patients who cannot reliably say whether they hit their head, such as those with delirium or dementia, should be treated as having a possible head injury.
Does a patient on anticoagulants need a CT scan after a fall?
NICE NG232 recommends considering a CT head scan within 8 hours of a head injury for people taking anticoagulants or antiplatelets (other than aspirin alone) who have no other indication for a scan, using shared decision-making. Some features require a scan within 1 hour. Make sure the reviewing doctor knows about the medicine and follow your local pathway.
How quickly should a doctor see a patient after a fall?
Your post-fall protocol sets the timescale. NICE quality standard QS86 refers to medical examination within a maximum of 12 hours, or within 30 minutes if fast-tracked because of signs of serious injury, high vulnerability to injury, or the patient having been immobilised. Many organisations set shorter times. Request review promptly, day or night.
What should I write in the notes after a patient falls?
Record the time and place, whether it was witnessed, what the patient and witnesses said, the checks done before moving and findings, how the patient was moved and with what equipment, observations including NEWS2, glucose and neuro obs, who was informed and when, any injuries and the plan, and changes to the falls prevention plan.
Do falls risk scores prevent falls?
NICE advises against using falls risk prediction tools to predict who will fall in hospital, because they are not accurate enough. Instead, NG249 recommends a multifactorial assessment that identifies each person's modifiable risk factors, such as medicines, low blood pressure on standing, delirium, continence, vision and footwear, and acting on each one.
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Sources and further reading
- Falls: assessment and prevention in older people and in people 50 and over at higher risk (NG249). National Institute for Health and Care Excellence.
- Head injury: assessment and early management (NG232). National Institute for Health and Care Excellence.
- Falls in older people quality standard (QS86). National Institute for Health and Care Excellence.
- Enduring standards: cross-specialty safety (care after an inpatient fall). NHS England.
- National Audit of Inpatient Falls: supporting best and safe practice in post-fall management. Royal College of Physicians.
- The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing and Midwifery Council.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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