The RCP’s National Audit of Inpatient Falls (NAIF) has produced a brand new post-fall medical examination resource that – for the first time – provides detailed guidance for healthcare practitioners (HCPs) assessing inpatients following an inpatient fall. Dr Sarah Howie, consultant physician in general and senior health medicine, explains how this new resource will help improve care on the wards.
Inpatient falls are a frequent, but potentially devastating, incident in healthcare organisations. Patient outcomes after a fall in an inpatient setting are much worse, especially if the fall results in an injury – 13% of patients who fracture their hip as an inpatient will die within 30 days.
The National Audit of Inpatient Falls, part of the Falls and Fragility Fracture Audit Programme (FFFAP), plays a crucial role in identifying how we can reduce harm for these patients. NAIF collects information about significant injuries sustained in inpatient settings in patients aged 65 and over, focusing on multifactorial assessment to optimise safe activity (MASA) and, if a fall occurs, immediate post-fall management of injuries. Up until 2025, it has focused exclusively on inpatients who sustain a hip fracture – but this year, the audit has expanded to include all fractures, head injuries and spinal injuries.
To support organisations to improve their performance, NAIF has produced a range of supporting resources, the most recent being the post-fall medical examination resource which provides detailed guidance for those healthcare practitioners (HCPs) performing the medical examination following an inpatient fall.
Impact of inpatient falls
Inpatient falls represent one of the most frequently occurring incidents in our healthcare organisations; there are around 247,000 falls in England per year alone (NAIF report 2020). By looking at the National Hip Fracture Database (NHFD) KPIs, we can see that performance in those patients who sustain a hip fracture as an inpatient, as opposed to in an outpatient setting, is worse when. Inpatients are more likely to die after their injury and less likely to return to their own home.
There are many possible explanations for this. These patients are more likely to be male, frail and cognitively impaired – all poor prognostic markers following a hip fracture. There is good evidence that surgery within 36 hours improves outcomes, but those who fall and fracture their hip as an inpatient are more likely to have their surgery delayed for medical reasons.
However, NAIF has also been able to show that one in four inpatients who sustain a hip fracture experience a delay in care, including accessing X-rays and orthopaedic assessment (NAIF report 2023).
These data highlight the need to not only prevent these injuries, but also to ensure prompt and excellent post-fall care when they do occur.
Post-fall medical examination: a guide for inpatient settings
In response to documented delays in care after an inpatient hip fracture, NAIF recognised the lack of guidance available specifically for HCPs performing the medical reviews after an inpatient fall. These HCPs have varying degrees of experience and training in the examination of patients who have sustained traumatic injuries, which is made more challenging by their medical complexity and frailty.
In contrast, many emergency department trauma triage systems identify older trauma patients as requiring assessment by more experienced staff. There is increasing recognition that a fall from a height of less than 2m is now the most common mechanism of injury in patients meeting the criteria for major trauma and – in those over 69 years old – the most common cause of trauma-related death.
NAIF has summarised existing guidance and adapted it for use in an inpatient setting for low-trauma injuries. As part of this post-fall medical examination resource, three documents are available:
1. Detailed explanatory notes which guide HCPs through each step of a medical examination. These have been formatted to be available via mobile phone or iPad to allow easy access while on the ward. This covers the following areas:
- The initial referral – SBAR information, urgency of review and instructions to nursing staff
- Dynamic risk assessment if the patient is still on the floor
- Primary survey
- Secondary survey covering: head, C-spine, thoracic / lumbar spine, chest, abdomen, hips and pelvis, four extremities
- Prompts to consider analgesia, anticoagulation and antiplatelets, and delirium
- Appropriate investigations
- Notes for community settings
- Checklist for handover to nursing staff, relevant documentation and plan to review investigations
- Points for parent multidisciplinary teams to consider
2. A proforma that prompts HCPs to address the essential areas and allows appropriate documentation that aligns with NAIF audit requirements.
3. An implementation toolkit that can be used to identify the competencies and training required – and identify any gaps in current provision.
The guidance and related resources were developed by a multidisciplinary task and finish group with representatives from orthopaedic, geriatric and emergency medicine, with experience of both acute and community inpatient settings.
Supporting our HCPs
For the first time, there is step-by-step guidance for HCPs reviewing patients on the wards following an inpatient fall.
This resource adds to guidance for first responders published in 2022. The proforma will support organisations to standardise the documentation of these assessments, and those responsible for training can identify potential areas that need to be addressed using the implementation toolkit. In 2026, NAIF plans to develop two e-learning modules to address training needs and further support post-fall care on the wards.
The hope is that these resources will go some way to reduce the delays in diagnosis of inpatient injuries and facilitate access to prompt specialist care to improve overall patient outcomes.
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