Background
Inpatient falls are the most reported patient safety incident in the NHS. It's estimated that in England alone, there are more than 240,000 inpatient falls every year. Older people (aged 65 and over) have the highest risk of injury, with two of the most severe fall-related injuries being head injury and hip fracture.
Around 2,000 inpatient hip fractures are reported in England and Wales each year (NAIF report 2024). People who sustain a hip fracture as a hospital inpatient are twice as likely to die within 30 days of the fracture (12.7% as opposed to 5.8% of falls in the community), and less likely to be discharged to their usual place of residence (47% as opposed to 70%), than those who sustain the same injury outside a hospital (NAIF report 2020).
Even without sustaining injury, inpatient falls lead to decreased confidence, deterioration in function and longer length of stay, and can be very distressing for the patient, their families and ward staff - as well as sometimes leading to complaints and litigation. In 2017, inpatient falls were estimated to cost the NHS £630m a year.
Current guidelines
To prevent falls in inpatient settings, evidence-based NICE guidelines and World Falls Guidelines recommend the following steps.
- Avoiding screening tools to classify risk of falls (as there are no tools with sufficient prognostic accuracy).
- Comprehensive assessment of fall risk factors with tailored interventions to address the factors identified.
- Tailored patient education to support patients in understanding their individual fall risk factors and their own role in modifying this risk.
The immediate management of inpatients who have fallen is likely to affect outcomes and patient experience. There are three NICE quality standards (QS86) on post-fall management:
- Standard 4: checking for injury before the patient is moved
- Standard 5: moving from the floor using 'safe' methods
- Standard 6: a medical assessment within an appropriate time frame (30 minutes where an injury is suspected and 12 hours where it is not).
The National Audit of Inpatient Falls
The National Audit of Inpatient Falls (NAIF) continuously audits the cases of patients in England and Wales who have fallen and sustained any fracture, head or spinal injury during an inpatient stay.
It began a decade ago, but moved to continuous data collection in 2019, measuring fall prevention activity and post-fall management in inpatients who had sustained a fall-related hip fracture. These patients could be identified through NAIF's sister audit, the National Hip Fracture Database.
From January 2025 the audit expanded to cover all fall-related fractures, head and spinal injuries sustained by hospital inpatients in England and Wales.
The aim of NAIF is to:
- provide national and trust level data on compliance with NICE CG161 and post-fall and NICE QS86
- evaluate organisational policy and processes through regular facilities audits
- support organisations to improve performance through data, educational resources and quarterly webinars
- help patients, their families and supporters to understand how to best prevent falls and how they can influence practice in their local hospital
- make recommendations for national initiatives to improve the management of inpatient falls.
Data is collected from the health records of all eligible patients and used to measure performance against four key performance indicators (KPIs), which are described in detail below.
KPI 1: Multifactorial assessment to optimise safe activity (previously known as multi-factorial fall risk assessment)
KPI 1 is based on documented evidence of the assessments listed below.
Visual impairment is a known risk factor for falls that is complicated by the unfamiliar hospital environment. Individual patient care plans should indicate where additional supervision or modifications to the environment are required because of visual impairment.
Orthostatic hypotension (OH) is the most common reason for syncope and pre-syncope in older people. Syncope can be mistaken for a fall and is associated with a higher risk of injury, and pre-syncope may lead to a person feeling dizzy and falling. Factors related to the inpatient admission (for example, sepsis or dehydration) increase the likelihood of OH.
OH can be addressed by reviewing medications to reduce those having an antihypertensive effect, ensuring good hydration, and in some cases treating with medication.
Taking multiple medications and/or central nervous system acting or antihypertensive medications are associated with higher falls risk. Medications can have different effects when someone is unwell, so a structured review in hospital is needed.
Even without sustaining injury, inpatient falls lead to decreased confidence, deterioration in function and longer length of stay, and can be very distressing for the patient, their families and ward staff...
Delirium is common in older people admitted to hospital and increases risk of falls through associated behaviours such as restlessness, impulsivity and inattention and the effects on balance and mobility.
Screening using the 4AT tool is recommended for all older people admitted to hospital. Effective management of delirium reduces risk of falling.
Continence assessment
Urinary incontinence is an important risk factor for falling. Urinary frequency and urgency, as well as fear of incontinence, increases the likelihood that patients will attempt to walk to the toilet without waiting for supervision when it is otherwise required.
Mobility assessment
To ensure people can move around safely while in hospital, all patients should have an assessment to determine supervision and walking aid requirements. This assessment should also consider how to support patients to stay physically active and engage in rehabilitation - in a way that minimises risk of falling while avoiding overtly restricting activity.
In 2024, NAIF intentionally changed the language and philosophy underpinning the assessment described above. The term 'risk assessment' implies avoidant action, which may lead ward staff to be fearful of encouraging movement because it increases exposure to falls (as falls only really happen when people are upright and moving around).
Hospital-acquired deconditioning (HAD) is common, especially in older patients, and can lead to longer length of stay, dependency, and in the long run increases risk of falling. Movement avoidance will undoubtedly reduce exposure to falling, but the resulting HAD is arguably an equally serious admission-related harm.
NAIF proposes instead to adopt constructive language and a philosophy that promotes activity by taking proactive actions to ensure the patient is 'fit to move'. It is important to note that this approach is not suggesting that falls are inevitable, but that it is critical to use the multi-factorial assessment to identify and address factors that impact on fitness to move.
![Components of the multi-factorial assessment to optimise safe activity (MASA). KPI 1 is the proportion of patients with a high-quality MASA (five or more of these assessments documented). In 2023, 39% of patients had a high-quality MASA. Figure taken from the NAIF 2024 Annual Report.]()
Components of the multi-factorial assessment to optimise safe activity (MASA). KPI 1 is the proportion of patients with a high-quality MASA (five or more of these assessments documented). In 2023, 39% of patients had a high-quality MASA. Figure taken from the NAIF 2024 Annual Report. Figure taken from the NAIF 2024 Annual Report.
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Post-fall management: KPIs 2, 3 and 4
KPI 2: check for injury before moving from the floor (aligns to NICE QS86 standard 4). A 'first responder' check should be done to establish whether injury is suspected. This is important to make sure the patient is moved from the floor safely and the medical assessment is sought in an appropriate timeframe.
KPI 3: safe moving and handling after an inpatient fall (aligns with NICE QS86 standard 5). This stipulates the selection of moving and handling equipment and techniques to avoid worsening of potential injuries.
For example, suspected spinal injury requires immobilisation, and those with suspected hip fracture should be moved using flat lifting equipment, as opposed to a sling hoist. On the occasions that patients get up before this check can be done, a post-fall medical assessment should still be undertaken to ascertain injuries.
KPI 4: medical examination after an inpatient fall (maps to NICE QS86 standard 6). This should be undertaken within 30 minutes if an injury is suspected and within 12 hours if not). As well as a primary and secondary survey to determine injuries sustained, it should also establish causes of falls requiring immediate management (for example, hypotension, sepsis, dehydration, delirium).
![KPIs 2, 3 and 4 illustrating performance in check for injury, safe method for moving from the floor and medical assessment within 30 minutes. Figure taken from the NAIF 2024 Annual Report.]()
KPIs 2, 3 and 4 illustrating performance in check for injury, safe method for moving from the floor and medical assessment within 30 minutes. Figure taken from the NAIF 2024 Annual Report.
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There has been a gradual improvement in KPI performance since the inception of the continuous audit Illustrated in figures 1, 2 and 3. However, there is still much scope for improvement and in delirium screening, performance is declining (see image above).
Medico-legal issues
The causes of falls are complex and there is no simple solution to their management. Assessment of risk factors with tailored interventions (as described above) has been shown in research to be an effective way to reduce falls.
However, not all falls are prevented by such interventions. Evidence synthesis of relevant studies found falls are reduced by around 20%. Therefore, some patients will unfortunately fall despite all actions being taken to reduce risk. And when participating in rehabilitation, there will be an element of risk as patients are encouraged to be more active and independent.
Investigations into fall events should evaluate whether appropriate risk reducing actions were implemented, and consider the potential harms of deconditioning and dependency if the patient had not been encouraged to be active at the time they fell.
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Effective post-fall management hinges on the check for injury being accurate, as many of the subsequent actions rely on this. This remains a challenge, as in 2023, injury was not suspected in the post-fall check of 31% of patients with a hip fracture (NAIF report 2024). NAIF has produced resources to support organisations in delivering effective post-fall checks.
We are in the process of producing resources for the post-fall medical examination. While it might be assumed that a patient who falls in hospital is 'in the best place', our data suggests the opposite - an example being that it takes on average 1.5 hours for analgesia to be administered after an inpatient fall-related hip fracture (NAIF report 2024).
We recommend organisations develop post-fall management policies and procedures appropriate to their size, acuity and medical cover to ensure effective and prompt care for inpatients.
A note on using falls rates
Auditing inpatient falls prevention and management requires accurate reporting, and all falls, regardless of injury, should be reported.
In the NHS, reports are fed into the Learning from Patient Safety Events (LfPSE) system. Accurate reporting allows organisations to better understand and explore patterns of falls, and to address systems and process challenges, in addition to patient-level clinical management (see PSIRF resources for more detail).
Effective post-fall management hinges on the check for injury being accurate, as many of the subsequent actions rely on this.
NAIF recommends organisations analyse falls rates per 1,000 occupied bed days to look for trends within their organisation, but to avoid comparisons with other organisations. Organisational falls rates can be influenced by population demographics, the built environment (for example, organisations with fully single room provision have higher falls rates) and reporting culture.
Underreporting of falls is common and organisations are encouraged to employ methods to establish its extent.
Conclusion
Falls frequently occur in inpatient settings. To prevent falls, it important to address risk factors to optimise a patient's fitness to move.
In the event of a fall, older people who experience an injury often experience poor outcomes. Effective post-fall management is required to ensure prompt and effective diagnosis and treatment of injury. NAIF measures whether these approaches are used.
With the expansion of the audit in 2025, we will be able to better understand how head injuries and other fractures are managed and use our data to drive improvement in these areas.
Supplementary information and links
RCP resources
Julie Whitney
Julie Whitney is an academic physiotherapist with an interest in fall prevention. She is the clinical lead for the National Audit of Inpatient Falls (NAIF). In addition, she works clinically at King's College Hospital falls clinic and has conducted a range of observational studies, trials and evidence syntheses on fall prevention. Julie is one of the members of the NICE guidelines committee for the new falls guidelines to be published in 2025.
See more by Julie Whitney