Recurring concern

Unreliable communication and understanding of emergency policies and procedures

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First reported 8 Jan 2016•Latest report 18 Mar 2026

Definition

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.

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
11

Distinct published reports

Individual concerns
11

A report can raise multiple concerns

Date range
2016–2026

First to latest report issue date

Stated actions
15

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service2
Alton Towers Resort1
Care Quality Commission1
Care UK1
College of Policing1
Cornwall and the Isles of Scilly Safeguarding Adults Board1
Drayton Manor Resort1
Dyfed-Powys Police1
Leeds City Council1
LEGOLAND Windsor Resort1
Lightwater Valley Family Adventure Park1
London Ambulance Service NHS Trust1
Merlin Entertainments Limited1
Metropolitan Police Service1
Musgrove Park Hospital1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  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
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Data last updated 7 September 2026