Falls are the third highest reported safety incident in Specialist Palliative Care in-patient settings and yet specific risk factors connected with falling and associated outcomes in this setting are poorly understood. To understand the key individualised risk factors leading to falls in specialist in-patient palliative care settings and understand the implications and outcomes for the patients who fall. A realist synthesis of the literature, reported following the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) standards. An iterative literature search was conducted across three recognised health collections as well as grey literature from policy, practice and other relevant areas. Falls taking place within in-patient specialist palliative care settings can cause significant harm to patients. The risk factors for these patients are multifaceted and often interlinked with underpinning complex realist mechanisms including a history of falls, the age of the person, impact of complex medications, improving functional status and the presence of delirium. In-patients in specialist palliative care settings are at risk of falling and this is multifactorial with complex reasoning mechanisms underpinning the identified risks. There is a significant impact of a fall in this cohort of patients with many sustaining serious harm, delayed discharge and both physical and psychological impacts.