Recurring concern

Unreliable personal emergency alarms for people requiring assistance

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First reported 5 May 2021•Latest report 6 Jun 2024

Definition

What this concern includes

Includes failures of personal emergency alarm devices and their dedicated support arrangements, including charging, testing, serviceability, repair, replacement and availability for people who rely on them to summon emergency or welfare assistance.

Not included

Excludes patient monitoring alarms, bed-exit alarms, call bells and other alarms whose primary function is to alert staff automatically rather than enable a person to summon assistance.
Excludes generic telecare-service governance or alarm-call handling failures unless the personal emergency alarm's availability or operation is itself deficient.
Excludes ordinary equipment maintenance or battery failures unrelated to a personal emergency alarm used to summon assistance.
Excludes failures occurring after a functioning personal emergency alarm has successfully raised an alert, including delayed staff or emergency-service response.

Reports: 3
Individual concerns: 6
Date range: 2021–2024
Stated actions: 8

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Leeds City Council1

London Borough of Hackney1

Options For Care Limited1

Supreme Care Services Limited1

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.

6 Jun2024
Inner North London
Concerns raised3
1. Failure to replace or repair reported-broken wrist alarms
2. Failure of attending carers to escalate reported wrist-alarm faults
3. Lack of training, instruction or guidance for carers on testing wrist alarms
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Report faulty pendants to the responsible telecare provider and commissioning local authority.
  Stated by Supreme Care Services LimitedStated completed
2. Action
  Audit TEC service providers and provide independent UKAS-accredited certification against the Quality Standards Framework.
  Stated by TEC Quality LtdStated completed
Respondent positions 3
1. Position
  Supplying, maintaining, repairing or replacing faulty pendants falls outside the domiciliary care provider’s role and contractual requirements.
  Stated by Supreme Care Services LimitedOutside remit
1. Position
  The telecare provider is responsible for supplying, routinely testing, monitoring, maintaining, repairing and replacing faulty pendants.
  Stated by Supreme Care Services LimitedRedirects responsibility
2. Position
  The local authority should take primacy to act and ensure repair or an alternative is commissioned for faulty pendants.
  Stated by Supreme Care Services LimitedRedirects responsibility
AI-generated summary

Anoush Summers · 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

Anoush Summers, a frail woman living alone, fell at home after her wrist alarm had been reported as broken and was found the following day. She was taken to hospital and died of hypothermia on 14 January 2024. Concerns included the failure to repair or replace the alarm, unclear reporting responsibilities, and inadequate instructions or training for carers regarding alarm faults and care notes.

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 to replace or repair reported-broken wrist alarms
Wider context from the report
“1. Although the wrist alarm had been reported as broken and not working on the 6.1.2024, this was not replaced or repaired by the company engaged by the local authority to provide this service before the deceased fell at home between 11-12.1.2024. ”
Source location
Anoush Summers · 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
Failure of attending carers to escalate reported wrist-alarm faults
Wider context from the report
“3. None of the carers who attended on the deceased after 6.1.2024 ensured that steps were taken to replace the wrist alarm or report the matter to the local authority. ”
Source location
Anoush Summers · Prevention of Future Deaths report
Page 3 · 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
Lack of training, instruction or guidance for carers on testing wrist alarms
Wider context from the report
“5. None of the carers had been given any training, instruction, or guidance on the testing of wrist alarms to ensure they worked properly when attending upon service users. ”
Source location
Anoush Summers · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Report faulty pendants to the responsible telecare provider and commissioning local authority.

Verbatim wording from the response
“notified to the local authority so they can take primacy to act and ensure that a repair or an alternative is commissioned.”

Source location
Response from Supreme Care Services Ltd
Page 4 · response
Published 14 June 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Audit TEC service providers and provide independent UKAS-accredited certification against the Quality Standards Framework.

Verbatim wording from the response
“We strive to ensure the quality and safety of TEC by setting and developing standards and providing independent and trusted audit and certification through our wholly owned subsidiary, TEC Quality Ltd, an accredited body by the United Kingdom Accreditation Service (UKAS).”

Source location
Response from TEC Quality on behalf of Hackney Council
Page 1 · response
Published 14 June 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Supplying, maintaining, repairing or replacing faulty pendants falls outside the domiciliary care provider’s role and contractual requirements.

Verbatim wording from the response
“4. The telecare provider ought to have been aware that the pendant was not working through its own testing.”

Source location
Response from Supreme Care Services Ltd
Page 1 · response
Published 14 June 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The telecare provider is responsible for supplying, routinely testing, monitoring, maintaining, repairing and replacing faulty pendants.

Verbatim wording from the response
“16. It remains the role of the telecare provider to monitor and replace any faulty pendants within the terms of its contractual arrangements with the funding authority and it is also their responsibility to routinely test pendants.”

Source location
Response from Supreme Care Services Ltd
Page 3 · response
Published 14 June 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The local authority should take primacy to act and ensure repair or an alternative is commissioned for faulty pendants.

Verbatim wording from the response
“notified to the local authority so they can take primacy to act and ensure that a repair or an alternative is commissioned.”

Source location
Response from Supreme Care Services Ltd
Page 4 · response
Published 14 June 2024
Open published response
23 Jun2021
West Yorkshire Eastern
Concerns raised1
1. Failure to check the availability and operation of personal alarm systems before vulnerable people return home
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Develop and deliver lessons-learned training for Mental Health Unit staff covering telecare, discharge planning, equipment checks, capacity recording and related safety processes.
  Stated by Leeds City CouncilStated planned
2. Action
  Establish a task-and-finish group to develop a discharge checklist covering utilities, safety equipment, environmental and occupational therapy assessments, and discharge-day home visits where indicated.
  Stated by Leeds City CouncilStated planned
3. Action
  Develop and publish guidance for the Conversation Record pro-forma covering medical needs, equipment and referrals, risk assessment, mitigation plans, service-user views, and documented capacity decisions.
  Stated by Leeds City CouncilStated planned
AI-generated summary

Netlyn Mae ROBINSON · 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

Netlyn Mae ROBINSON returned home on 2 October 2020 after adaptations for her reduced mobility, with three daily care visits. She was found the following morning at the dining table having choked on food. The report identified concerns about the absence of a falls alarm and working telephone, lack of risk assessment and checks for heating, water and smoke alarms, and insufficient processes for assessing whether her home was safe for her return.

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 to check the availability and operation of personal alarm systems before vulnerable people return home
Wider context from the report
“(1) In evidence it became apparent that there was no falls pendant or alarm provided on Mrs Robinson’s return home despite her previously having one when last at home. There appeared to be no process in place to check whether there was a fully operational alarm system in place when needed. Further that Mrs Robinson was not consulted about the lack of an alarm until she had arrived home, thus no process in place to provide a person with relevant information in order that they are able to decide whether or not to return to their home address without any form of alarm. ”
Source location
Netlyn Mae ROBINSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and deliver lessons-learned training for Mental Health Unit staff covering telecare, discharge planning, equipment checks, capacity recording and related safety processes.

Verbatim wording from the response
“Lessons Learnt Training Session (applies to points 1-6)”

Source location
2021-0219-Response-from-Leeds-City-Council_Published
Page 2 · response
Published 28 June 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Establish a task-and-finish group to develop a discharge checklist covering utilities, safety equipment, environmental and occupational therapy assessments, and discharge-day home visits where indicated.

Verbatim wording from the response
“Discharge Checklist/Crib Sheet (applies to points 1,2,3,4,6)”

Source location
2021-0219-Response-from-Leeds-City-Council_Published
Page 2 · response
Published 28 June 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and publish guidance for the Conversation Record pro-forma covering medical needs, equipment and referrals, risk assessment, mitigation plans, service-user views, and documented capacity decisions.

Verbatim wording from the response
“Conversation Record Pro-Forma Guidance Notes (applies to points 1,5,6)”

Source location
2021-0219-Response-from-Leeds-City-Council_Published
Page 3 · response
Published 28 June 2021
Open published response
5 May2021
Birmingham and Solihull
Concerns raised2
1. Failure to ensure staff awareness and training on the PIT alarm charging policy
2. Failure to ensure PIT alarms are charged and operational
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Reinforce the PIT alarm procedures and security lead arrangements through staff meetings.
  Stated by Options for CareStated planned
2. Action
  Operate a security lead role each shift to check, issue, replace, recover, record and charge PIT alarms.
  Stated by Options for CareStated completed
3. Action
  Use clinical staff supervision sessions to reinforce PIT alarm fault reporting, replacement access, security lead responsibilities and alarm testing.
  Stated by Options for CareStated planned
Respondent positions 1
1. Position
  Existing changes at Dartmouth House are considered sufficient to meet the Regulation 28 requirements concerning PIT alarms and staff training.
  Stated by Options for CareExisting arrangements considered sufficient
AI-generated summary

Stephen Anthony MAGUIRE · 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

Stephen Anthony MAGUIRE collapsed while eating lunch at a mental health facility on 14 September 2020 and died after a mass of chewed meat obstructed his airway, causing approximately 30 minutes without oxygen. The report raised concerns that a staff member's personal incident and threat (PIT) alarm was not charged and that staff, including agency workers, might be unaware of the charging system or insufficiently trained in it.

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 to ensure staff awareness and training on the PIT alarm charging policy
Wider context from the report
“2. I heard evidence that ████████ was an agency worker working for Options for Care at the time of Mr Stephen Anthony MAGUIRE's death, and there was a suspicion (but which could not be proven) that they may have either been unaware of the charging system, or made a simple error. Although not causative in Mr Stephen Anthony MAGUIRE's death, if members of staff (both full time and agency workers alike) are unaware of the charging policy, or are not trained and reminded in the same, there is the risk of death if a member of staff is unable to utilise their own PIT alarm in an emergency due to the same not being charged. ”
Source location
Stephen Anthony MAGUIRE · 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
Failure to ensure PIT alarms are charged and operational
Wider context from the report
“1. I heard evidence that the PIT alarm used by staff member, ████████, did not work when pressed. I heard evidence this was alarm was checked after the incident and found to not have been charged. I heard evidence from the ████████ ████████ that Options for Care Limited have a system whereby it is the night staffs’ responsibility to check and charge the PIT alarms overnight, and it is the responsibility of the day care staff to check that their PIT alarms are charged and operational when they come on shift in the morning ("the charging system"). Somehow, this charging system failed. Although not causative in Mr Stephen Anthony MAGUIRE's inquest, if a member of staff is unable to utilise their own PIT alarm in an emergency, this creates an obvious risk of death to both service users and staff alike. ”
Source location
Stephen Anthony MAGUIRE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Reinforce the PIT alarm procedures and security lead arrangements through staff meetings.

Verbatim wording from the response
“These actions and changes will be further reinforced through staff meetings.”

Source location
2021-0138-Response-from-Dartmouth-House-Redacted
Page 2 · response
Published 5 May 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Operate a security lead role each shift to check, issue, replace, recover, record and charge PIT alarms.

Verbatim wording from the response
“Dartmouth House has instituted an operational change with the introduction of a ‘security lead’ role. This is allocated to an appropriately experienced clinical staff member on commencement of each shift.”

Source location
2021-0138-Response-from-Dartmouth-House-Redacted
Page 1 · response
Published 5 May 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use clinical staff supervision sessions to reinforce PIT alarm fault reporting, replacement access, security lead responsibilities and alarm testing.

Verbatim wording from the response
“Options for Care has an existing system of Review and Feedback (supervision) sessions for clinical staff each facilitated by an appropriate line manager. To strengthen existing systems and processes, the management team will utilise these sessions to:”

Source location
2021-0138-Response-from-Dartmouth-House-Redacted
Page 1 · response
Published 5 May 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing changes at Dartmouth House are considered sufficient to meet the Regulation 28 requirements concerning PIT alarms and staff training.

Verbatim wording from the response
“I trust these changes already in place at Dartmouth House effectively meet the requirements of the actions which should be taken as identified in the Regulation 28 report. Should you require any further information or clarification, please do not hesitate to contact me.”

Source location
2021-0138-Response-from-Dartmouth-House-Redacted
Page 2 · response
Published 5 May 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Failure to replace or repair reported-broken wrist alarms

Failure of attending carers to escalate reported wrist-alarm faults

Lack of training, instruction or guidance for carers on testing wrist alarms

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to check the availability and operation of personal alarm systems before vulnerable people return home

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised2

Failure to ensure staff awareness and training on the PIT alarm charging policy

Failure to ensure PIT alarms are charged and operational

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 2

Respondent positions 3

Actions described in response 3

Actions described in response 3

Respondent positions 1