Post-Fall Reviews in Dementia: Turning Incidents into Safer Practice
In dementia services, a fall should never be treated as an isolated event. Each incident is a signal that something in the system, routine or environment needs adjustment. Providers operating within Medicines, Frailty, Falls & Safety must show how post-fall reviews translate into safer practice across their Dementia Service Models, not just additional paperwork.
Why post-fall reviews often fail
Many services complete incident forms but fail to reduce repeat falls. Common weaknesses include:
- Focusing on the fall itself rather than the preceding hour
- Generic actions that do not reflect the individual
- No ownership or timescales for changes
- Lack of service-level pattern analysis
An effective post-fall review asks not “what happened?” but “what changed and why?”
Commissioning and inspection focus
Commissioner expectation: learning-led incident management
Commissioners expect evidence that falls lead to improvement. This includes timely reviews, documented actions, and demonstrable impact on future risk.
Regulator / Inspector expectation: responsive and safe care
Inspectors will test whether services respond appropriately after incidents, update risk assessments, involve families, and reduce repeat harm.
What a meaningful post-fall review includes
A structured review typically covers:
- Immediate cause and contributing factors
- Physical health checks and follow-up
- Environmental conditions
- Staff response and decision-making
- Changes required and who owns them
Operational example 1: Repeated falls at the same time of day
Context: A resident falls twice in one week at around 4pm while moving between lounge and bathroom.
Support approach: The review maps the routine before each fall, identifying fatigue and toileting urgency as common factors.
Day-to-day delivery detail: Staff introduce planned toileting at 3.30pm, ensure clear routes, and increase supervision during this high-risk window. Hydration timing is adjusted earlier in the afternoon.
How effectiveness is evidenced: No further falls occur at this time over the next month, and incident analysis confirms risk reduction.
Looking beyond the environment
While clutter and flooring matter, post-fall reviews should also consider:
- Recent medication changes
- Sleep disruption or infection
- Emotional distress or behavioural changes
- Staffing consistency and familiarity
Operational example 2: Medication-related dizziness
Context: A person falls shortly after standing in the morning following a recent medication change.
Support approach: Staff escalate immediately, linking the fall to possible postural hypotension.
Day-to-day delivery detail: The team implements slow-rise support, hydration prompts, and morning supervision while awaiting GP review.
How effectiveness is evidenced: Medication is adjusted, dizziness resolves, and no further morning falls occur.
Service-level learning from falls data
Individual reviews must feed into wider learning. Effective governance includes:
- Monthly falls trend analysis
- Identification of repeat patterns
- Targeted staff coaching
- Environmental or process changes tracked to completion
Operational example 3: Reducing falls through staff coaching
Context: Multiple falls occur during transfers across different residents.
Support approach: Management identifies inconsistent transfer techniques as a contributing factor.
Day-to-day delivery detail: Refresher coaching is delivered on safe transfers, with observed practice and supervision follow-up.
How effectiveness is evidenced: Transfer-related falls reduce significantly, and competency records confirm improved staff practice.
Closing the loop with families
Transparent communication reassures families and supports shared decision-making. Services should document:
- What happened and why
- What has changed as a result
- How risks will be reviewed
What good post-fall practice looks like
In high-quality dementia services, falls trigger learning, not repetition. Reviews are timely, practical and person-centred. Actions are implemented, monitored and adjusted. This approach reduces harm, supports independence, and demonstrates robust governance to commissioners and inspectors.