Abstract Background Falls events are a leading reason for presentations to the ED, particularly in older adults. Often these events are unwitnessed and unexplained. Therefore, there is strong consensus that the management of unexplained falls should be evaluated in a similar fashion to syncope as outlined by the World Falls and European Society of Cardiology guidelines. Methods The aim of this study was to evaluate adherence with current falls/syncope guidelines. Consecutive patients over the age of 75 who presented with a fall or syncope to a university teaching hospital in October 2023 were included. Data was collected on diagnostics completed (ECG, CT Brain, Carotid Doppler Ultrasound, EEG, pro BNP, Troponin, Echocardiogram, and External loop recorder), whether specialist falls review was performed, and readmission within 6 months. Completion of diagnostic tests were compared between those who were and were not reviewed by a specialist service using the Chi squared test. Results Falls/syncope/presyncope comprised 17.5% (160/913) of presentations of older people to the ED. Overall, 43% (n=68) had an ECG completed, 15% (n=23) had a pro BNP, and 24% (n=38) had a troponin level measured, 11% (n=17) had an Echo performed, and 10% (n=16) had prolonged cardiac monitoring (R test), 47% (n=74) had a CT Brain performed. Among those who were reviewed by a specialist falls service, (39% n= 62) completion of recommended investigations was significantly higher; ECG (69% v 26%, p<0.01), pro BNP (24% v 8.3%, p<0.01), echocardiogram (21% v 4.2%, p<0.01), cardiac monitoring (18% v 5.2%, p<0.01). Conclusion Falls and syncope are common presentations to the ED among older adults. Patients who were seen by a specialist falls team were more likely to have the appropriate diagnostics complete. Therefore, a specialist falls/syncope pathway led by a specialist falls service in the ED could result in better outcomes for patients.