Recurring concern

Unreliable response to falls-detection alarms

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First reported 31 Mar 2015•Latest report 23 Oct 2018

Definition

What this concern includes

Includes failures in the dedicated response to falls-detection alarms, including alarm prioritisation, staffing and responder deployment, one-person-unit policies, escalation when demand exceeds capacity, and arrangements for responding when the person cannot communicate verbally.

Not included

  • Excludes generic ambulance delays or emergency-service capacity problems where the falls-detection alarm response process is not itself deficient.
  • Excludes general staffing shortages unless they directly impair response to falls-detection alarms.
  • Excludes failures in the design, activation or maintenance of falls-detection devices where the response process is not the deficient control.
  • Excludes clinical assessment or treatment after responders or emergency services have reliably attended.
Reports
2

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2015–2018

First to latest report issue date

Stated actions
0

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.

Care4you – City Wide Alarms1
Sheffield City Council1
South Tyneside Borough Council1

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. South Yorkshire (Western)

    AI-generated summary

    Allan Herbert Shepard · 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

    Allan Herbert Shepard, aged 89, fell at home on 8 February 2018 while being assisted out of his wheelchair and remained trapped in a hoist awaiting help. His breathing deteriorated, and he lost consciousness from positional asphyxiation before the ambulance attended; he died later that day in hospital. The concerns related to responder staffing and policies for single-person units, and to outdated information about Mr Shepard and his family situation held by the call-handling service.

    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

    Failure of one-person responder units to attend falls when assistance is required

    Wider context from the report

    “(1) City Wide Care Alarm Service’s own guidance requires where there has been a fall a response should be provided within 30 minutes. During the time period when Mr Shepard was waiting for a response, there were two units available, However, one of the units was made up of only one person. The two person unit was engaged answering other calls in the 30 minutes following Mr Shepard’s alert. The one person responder unit was available to attend calls during this 30 minutes period but could attend a fall to provide assistance. Although the ambulance was contacted their response time was given as 4 hours. This 50% reduction in responders available to answer calls may risk further deaths when a person has suffered a fall. Therefore, City Wide Care Alarm Service is invited to consider its staffing levels and systems for providing cover. It is also invited to reconsider its policy regarding one person responder units when the injured person is already attended by someone else who may be able to assist. ”

    Source location

    Allan Herbert Shepard · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient responder staffing and cover for falls

    Wider context from the report

    “(1) City Wide Care Alarm Service’s own guidance requires where there has been a fall a response should be provided within 30 minutes. During the time period when Mr Shepard was waiting for a response, there were two units available, However, one of the units was made up of only one person. The two person unit was engaged answering other calls in the 30 minutes following Mr Shepard’s alert. The one person responder unit was available to attend calls during this 30 minutes period but could attend a fall to provide assistance. Although the ambulance was contacted their response time was given as 4 hours. This 50% reduction in responders available to answer calls may risk further deaths when a person has suffered a fall. Therefore, City Wide Care Alarm Service is invited to consider its staffing levels and systems for providing cover. It is also invited to reconsider its policy regarding one person responder units when the injured person is already attended by someone else who may be able to assist. ”

    Source location

    Allan Herbert Shepard · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Newcastle Upon Tyne

    AI-generated summary

    Olive Nugent · 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

    Olive Nugent fell down the stairs at home on 16 December 2014 and her falls detector activated, but no warden attended for 2 hours and 27 minutes. She sustained an unsurvivable brain injury and died. The principal concerns were delayed and subjective prioritisation of responses, insufficient staffing, and the risk to people who were unable to respond verbally through the device.

    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

    Subjective prioritisation of response to falls detection device activation

    Wider context from the report

    “(1) Mrs Nugent lay critically injured in her home for 2 hours and 27 minutes without assistance or access to medical treatment. (2) Her falls activator device had activated automatically indicating that she had fallen. (3) Her inability to respond verbally to call handlers via the device was a crucial factor in the decision not to prioritise her case. (4) Priority was given to clients whose devices had activated in some cases at a time later than Mrs Nugent's but who had been able to verbally respond to call handlers via their devices. (5) The prioritising of response to device activation is entirely subjective and heavily dependent upon (a) staffing levels and (b) the personal practices of individual team leaders. (6) On 16th December 2014 there were insufficient staff to meet the demand for assistance. This contributed to the delayed response to Mrs Nugent's needs. (7) A review of the Guidance to be adopted when responding to device activation was undertaken following Mrs Nugent's death. (8) The Policy Document entitled "Mobile Response Time Targets, Prioritising Mobile Response and Escalation Process", however, reaffirms that prioritisation of response remains a subjective process. A proposed escalation process in the event of demand exceeding the capacity of available staff is dependent upon other agencies whose availability is not guaranteed or the subject of any Memorandum of Understanding. (9) The provision of Falls Detection Devices is intended to ensure timely aid and assistance including medical treatment of injuries if required to vulnerable persons in the event of a fall. (10)Further deaths could potentially occur in the future; particularly in cases of persons injured and unable to respond verbally to call handlers. (11)Review of the Guidance and Policy Document and staffing levels is necessary to reduce this risk. ”

    Source location

    Olive Nugent · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to prioritise fall-device activations from persons unable to respond verbally

    Wider context from the report

    “(1) Mrs Nugent lay critically injured in her home for 2 hours and 27 minutes without assistance or access to medical treatment. (2) Her falls activator device had activated automatically indicating that she had fallen. (3) Her inability to respond verbally to call handlers via the device was a crucial factor in the decision not to prioritise her case. (4) Priority was given to clients whose devices had activated in some cases at a time later than Mrs Nugent's but who had been able to verbally respond to call handlers via their devices. (5) The prioritising of response to device activation is entirely subjective and heavily dependent upon (a) staffing levels and (b) the personal practices of individual team leaders. (6) On 16th December 2014 there were insufficient staff to meet the demand for assistance. This contributed to the delayed response to Mrs Nugent's needs. (7) A review of the Guidance to be adopted when responding to device activation was undertaken following Mrs Nugent's death. (8) The Policy Document entitled "Mobile Response Time Targets, Prioritising Mobile Response and Escalation Process", however, reaffirms that prioritisation of response remains a subjective process. A proposed escalation process in the event of demand exceeding the capacity of available staff is dependent upon other agencies whose availability is not guaranteed or the subject of any Memorandum of Understanding. (9) The provision of Falls Detection Devices is intended to ensure timely aid and assistance including medical treatment of injuries if required to vulnerable persons in the event of a fall. (10)Further deaths could potentially occur in the future; particularly in cases of persons injured and unable to respond verbally to call handlers. (11)Review of the Guidance and Policy Document and staffing levels is necessary to reduce this risk. ”

    Source location

    Olive Nugent · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026