Recurring concern

Unreliable communication and understanding of emergency policies and procedures

First to latest report 8 Jan 2016 — 18 Mar 2026

Reports that mention this concern
11
Times this concern has been raised
11
Stated actions linked to this concern
15

What this concern includes

Includes failures of the dedicated process for communicating, acknowledging, maintaining understanding of and applying emergency policies and procedures, including local variation, staff receipt and comprehension, acknowledgement controls and assurance that personnel know which emergency procedures apply.

What is not included
  • Excludes generic staff training, communication or documentation deficiencies unless they directly concern emergency policies and procedures.
  • Excludes failures in the substantive design or clinical adequacy of an emergency procedure where communication, understanding or application is not the shared unsafe condition.
  • Excludes non-emergency policies and procedures unless the report explicitly links them to the same emergency-policy communication and understanding process.
  • Excludes operational failures occurring after personnel have reliably received, understood and applied the applicable emergency policies and procedures.

Reports and published responses 11 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Cornwall

    AI-generated summary

    Norman Dorn · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Norman Dorn was found presumed dead in an armchair at a residential home after eating a jam sandwich, with food in his mouth. He was known to have swallowing problems, and staff did not remove the food or attempt resuscitation; the report also states that the GP and other emergency services did not attend in a timely manner. The concerns included whether care homes had adequate policies and staff training for recognising or confirming death and for resuscitation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of appropriate care-home resuscitation policies and staff preparation to preserve life

    Wider context from the report

    “2. That some care home in Cornwall may not have an appropriate resuscitation policy in place to ensure that all attempts have been made to preserve life (when appropriate). If such policies are in place that they are regularly updated and staff are made aware of them and given the appropriate training. ”

    Source location

    Norman Dorn · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026