Recurring concern

Unreliable access to emergency communication

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First reported 6 Jun 2014•Latest report 15 Apr 2025

Definition

What this concern includes

Includes failures of dedicated emergency communication facilities or arrangements where their unavailability, inaccessibility or unreliable operation can delay emergency assistance, including telephones, alarms, radios or equivalent means.

Not included

  • Excludes inaccurate triage or categorisation of emergency calls.
  • Excludes failures to record, route or share information after a communication has been received unless the report directly identifies this as a failure of the emergency communication access arrangement.
  • Excludes ordinary customer-service or routine telephone-access problems without an emergency-response function.
  • Excludes hazards created by telephone equipment, such as ligature risks, where the concern is the equipment's physical safety rather than access to emergency communication.
Reports
46

Distinct published reports

Individual concerns
49

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
51

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.

Department of Health and Social Care7
NHS England5
Association of Ambulance Chief Executives3
Health and Safety Executive3
Care Quality Commission2
HM Prison and Probation Service2
London Ambulance Service NHS Trust2
National Highways2
Winchester Prison2
Wolverhampton City Council2
Abbey Healthcare1
Appello Limited1
Bourne Leisure Limited1
Bow School1
British Heart Foundation1

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. London Inner (South)

    AI-generated summary

    ANNABEL NEWPORT · 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

    Annabel Newport collapsed shortly after boarding a train on 21 March 2018 and received CPR from passengers, but there was no defibrillator on board. She was taken to hospital after the train reached Waterloo and died two days later from brain damage suffered during cardiac arrest. The principal concerns were the lack of defibrillators, insufficient first-aid awareness among railway staff, and limitations in the operation of the emergency alarm system.

    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 the Pass-Com alarm to remain available after activation without guard reset

    Wider context from the report

    “(iii) The operation of the Pass-Com emergency alarm system 7. The Pass-Com is the emergency passenger alarm system found in the South Western Railway train carriages. It is understood that this may feature on other Train Operating Companies’ trains. Due to the operation of the alarm if it is activated by the passenger, once the call is terminated by the driver the alarm cannot be used again until the guard has re-set it. 8. In this case, the guard could not be located and so the alarm could not be used. Accordingly, a passenger took it upon himself to walk through the train to alert the driver to Ms Newport’s condition and lost potentially valuable time in order to do so. This may have contributed to the delay in her receiving ambulance treatment. The passenger did not appear to have realised that he could use a Pass-Com in another carriage. This may have been due to the stressful situation he found himself in, which is quite likely to occur if someone has used the Pass-Com due to a medical emergency. 9. There is a concern that it is not sufficiently apparent to passengers that once the Pass-Com has been used once, it cannot be used again without being re-set by the guard, and that in those circumstances they should immediately go to the next carriage to use the one there. ”

    Source location

    ANNABEL NEWPORT · Prevention of Future Deaths report
    Page 3 · 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

    Update Pass-Com emergency guidance so Drivers advise passengers to use another emergency alarm and Guards are reminded to reset the device.

    Verbatim wording from the response

    “37 The Coroner suggested we might put signage next to the Pass-Com. However, our concern is that this might not be read by a passenger under the pressure of acting in an unexpected emergency. We think that the best way to address that concern is for Drivers, receiving a Pass-Com communication, to advise the passenger about this limitation. We have therefore updated the Driver’s section of the Booklet to reflect this. In particular, the start of the Driver’s step-by-step guide to responding to an ill passenger incident begins [emphasis added]:”

    Source location

    2019-0240-Response-by-South-Western-Railways
    Page 6 · response
    Published 12 September 2019

    Open published response
  2. Buckinghamshire

    AI-generated summary

    Emma Felicity BUTLER · 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

    Emma Butler was an inpatient at Ruby Ward who died at Stoke Mandeville Hospital from blood loss after incised wounds inflicted outside the Whiteleaf Centre while she was on unescorted leave. The report raised concerns about access to means of self-harm on and outside the ward, hourly observations, urgent access to ward support, and planning for discharge.

    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

    Unavailability of immediate support or assistance through the specific ward number

    Wider context from the report

    “(4) Urgent or emergency access to the ward phone. The concern remains that a patient on unescorted leave outside the Centre who felt they were going to self- harm or who had self-harmed may not get immediate access to support or assistance by calling the specific ward number given to them. Whilst the evidence indicated the balance between positive risk taking, unescorted leave and taking responsibility for decisions and actions, the risk remains that the safety net is not sufficiently robust to ensure that if such a potentially fatal incident occurs, or is likely to occur, a patient can self-alert the ward and expect to receive an immediate response. ”

    Source location

    Emma Felicity BUTLER · 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

    Review the leave documentation and welcome pack to clarify phone availability and emergency arrangements for patients on leave.

    Verbatim wording from the response

    “One action that was discussed was to make it explicit within the leave documentation and welcome pack that when patients are on leave it is possible that the ward phone may not be answered, due to staff attending to the needs of patients on the ward; and to suggest to patients going on leave that if they feel the need to speak to a member of staff, it is suggested that they return to the ward, and speak with their allocated nurse. It should also underline that the ward is not able to provide an immediate response to patients who are on leave and that if patients require an urgent response whilst away from the ward they should contact the emergency services.”

    Source location

    2019-0133-Response-by-Oxford-Health-NHS-Trust
    Page 4 · response
    Published 14 June 2019

    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 ward cannot guarantee an immediate phone response because staff must prioritise patients physically present on the ward.

    Verbatim wording from the response

    “I understand that our (then) Ruby ward Modern Matron confirmed in evidence that it is possible that the ward phone number given to patients will go unanswered at times, if a patient on leave (or a relative) attempts to make contact; and that it is right that the focus of ward staff on shift should be towards meeting the needs of patients who are physically present on the ward. Although ward staff have a role in attempting to ensure the safety of”

    Source location

    2019-0133-Response-by-Oxford-Health-NHS-Trust
    Page 3 · response
    Published 14 June 2019

    Open published response
  3. Manchester North

    AI-generated summary

    Mr Gregory Rekowski · 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

    Mr Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.

    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 ward staff awareness of telephone restrictions affecting 111 calls

    Wider context from the report

    “Non of the ward staff were aware of the restrictions on the ward telephones which prohibit 111 calls from being, this meant time was spent trying to make such calls. ”

    Source location

    Mr Gregory Rekowski · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Nottinghamshire

    AI-generated summary

    Richard John Hill · 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

    Richard John Hill died on 17 August 2018 when he was struck by a London North Eastern train near the Cromwell Lane level crossing, also known as the Norwell Lane level crossing, near Newark, Nottinghamshire. The concerns identified were that the crossing had no telephones, no displayed contact telephone for Network Rail, and a possibility of a repeat incident at or near the location in the future.

    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

    Absence of telephones at the crossing

    Wider context from the report

    “1. That the British Transport Police post incident site report, by Paul Hardy, a copy of which has been sent to you, states the following: 1.1 There are no telephones at the crossing. 1.2 No contact telephone for Network Rail is displayed at the crossing. 1.3 There is a possibility of a repeat incident at or near to this location in the future and that Network Rail staff should be made aware of this. ”

    Source location

    Richard John Hill · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    A telephone is not required because CCTV monitoring, emergency services and Network Rail’s emergency number provide sufficient reporting arrangements.

    Verbatim wording from the response

    “There is no requirement for a telephone Cromwell Lane level crossing because it is a CCTV monitored crossing. Should a member of the public be concerned about an emergency situation, this should be reported by calling 999. Network Rail also maintains a 24 hour emergency number (03457 11 41 41) for the reporting of safety incidents on or near the railway, details of which are widely publicised. The emergency services closely liaise with Network Rail to pass information to signallers where required.”

    Source location

    Richard-Hill-Response
    Page 3 · response
    Published 15 November 2018

    Open published response
  5. Inner North London

    AI-generated summary

    Catherine Mary GIBBON · 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

    Catherine Mary Gibbon suffered a seizure while swimming at a gym on 1 June 2018 and remained face down in the water for around ten minutes. She sustained a hypoxic-ischaemic brain injury following non-fatal drowning and died. Concerns included inadequate pool monitoring and CCTV arrangements, a broken camera, insufficient staff training and emergency equipment, and gaps in first-aid certification systems.

    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

    Absence of a building-wide audible emergency alarm

    Wider context from the report

    “6. There was no panic button that would activate an audible alarm throughout the building, so anyone pressing a button would not know if it had alerted others, and staff elsewhere (other than at reception) would be unaware that there was an emergency. ”

    Source location

    Catherine Mary GIBBON · 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

    Absence of immediate poolside telephone access for summoning medical assistance

    Wider context from the report

    “7. There was no landline at poolside that could be used to call an ambulance in case of emergency, to enable medical assistance to be summoned immediately by someone who actually had sight of the casualty. ”

    Source location

    Catherine Mary GIBBON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  6. Inner North London

    AI-generated summary

    Kamal Yahyia AL-HIRSI · 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

    Kamal Yahyia AL-HIRSI, a cleaner at a London health club, suffered a cardiac arrhythmia and slipped beneath the water while cleaning the swimming pool on 10 October 2017. Resuscitation attempts were too late to change the outcome. Concerns included dangerous pool-cleaning practices, inadequate water-safety and defibrillator training, ineffective emergency alarms and communication, limited CCTV coverage, and procedures that remained substantially unchanged ten months after his death.

    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 emergency communication routes to reliably contact the duty manager

    Wider context from the report

    “6. The protocol in place was that, on hearing an alarm, the receptionist should simply contact the duty manager (who was the designated site first aider): first by radio; failing that by sending someone to find him; and failing that by ringing the duty manager’s mobile phone. The receptionist gave evidence that the radios often didn’t work, though the regional manager disagreed. When the receptionist was notified that there was an emergency, she could not use the radio because the duty manager had not picked a radio up; she was unsure where he was; and when she rang him on his mobile, she did not get through because there is a poor reception in the plant room where he was working. ”

    Source location

    Kamal Yahyia AL-HIRSI · Prevention of Future Deaths report
    Page 3 · 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

    Amend emergency procedures and notification processes, and retrain receptionists on alarm recognition and immediate response.

    Verbatim wording from the response

    “The Company has reviewed and amended its EAP, procedures and notification process for emergencies at the Maida Vale Club. Receptionists have been re-trained in recognising an alarm and the immediate next steps to be taken. The panic buttons when pressed will activate an automated message, which will be audible from all member areas of the Club and will notify all staff, including the Duty Manager(s), to muster at the Club’s Reception. The Duty Manager will dispatch employees to the emergency together with the Defibrillator and the other emergency equipment. The Company’s contractors will complete the installation work by 10 October 2018. It is the Company’s intention to pilot this revised emergency response system at its Maida Vale and Durham health clubs. Following a review of these systems, the Company intends to roll it out across its estate.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 3 · response
    Published 11 October 2018

    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

    Install an automated panic-button message audible throughout member areas and notifying staff to muster at reception.

    Verbatim wording from the response

    “The Company has reviewed and amended its EAP, procedures and notification process for emergencies at the Maida Vale Club. Receptionists have been re-trained in recognising an alarm and the immediate next steps to be taken. The panic buttons when pressed will activate an automated message, which will be audible from all member areas of the Club and will notify all staff, including the Duty Manager(s), to muster at the Club’s Reception. The Duty Manager will dispatch employees to the emergency together with the Defibrillator and the other emergency equipment. The Company’s contractors will complete the installation work by 10 October 2018. It is the Company’s intention to pilot this revised emergency response system at its Maida Vale and Durham health clubs. Following a review of these systems, the Company intends to roll it out across its estate.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 3 · response
    Published 11 October 2018

    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

    Pilot the revised emergency response system at the Maida Vale and Durham health clubs.

    Verbatim wording from the response

    “The Company has reviewed and amended its EAP, procedures and notification process for emergencies at the Maida Vale Club. Receptionists have been re-trained in recognising an alarm and the immediate next steps to be taken. The panic buttons when pressed will activate an automated message, which will be audible from all member areas of the Club and will notify all staff, including the Duty Manager(s), to muster at the Club’s Reception. The Duty Manager will dispatch employees to the emergency together with the Defibrillator and the other emergency equipment. The Company’s contractors will complete the installation work by 10 October 2018. It is the Company’s intention to pilot this revised emergency response system at its Maida Vale and Durham health clubs. Following a review of these systems, the Company intends to roll it out across its estate.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 3 · response
    Published 11 October 2018

    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

    Review emergency action procedures, procedures and notification processes across all sites.

    Verbatim wording from the response

    “The Company has also reviewed its EAPs, procedures and notification processes across all of its sites.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 4 · response
    Published 11 October 2018

    Open published response
  7. Suffolk

    AI-generated summary

    ASHLEY ERNEST NOTSON · 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

    Ashley Notson died at age 55 after choking on a piece of meat at the care home where he lived, later dying in hospital from hypoxic brain injury resulting from the choking episode. The inquest raised concerns that the law did not require care-home carers to have first-aid training or to have access to a mobile or portable telephone to summon assistance without leaving the person they were caring for.

    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 a legal requirement for care-home carers to carry a mobile or portable telephone for summoning assistance

    Wider context from the report

    “The inquest heard that the law currently does not require care providers to ensure that carers in a care home have had first aid training. Fortunately, the carer on duty at the time of incident was trained in first aid and did what he could to assist Ashley, but a similar situation could clearly arise in another care home without such a suitably trained carer present. The inquest also heard that, at this care home, all carers carry a mobile or portable telephone so that they can summon assistance if an incident occurs without having to leave the person they are looking after, but that this was not a legal requirement either. ”

    Source location

    ASHLEY ERNEST NOTSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  8. Inner West London

    AI-generated summary

    Ms Ivanika Olivari · 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

    Ms Ivanika Olivari died on 3 August 2017 at St George’s Hospital after suffering a cardiac arrest at home associated with a malfunctioning pacemaker. The principal concerns were failures to leave a message or use all available contact numbers in an urgent situation, and the need for guidance, policies and staff training to prioritise risk to life and permit appropriate messages to patients.

    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 leave answerphone messages enabling patient contact in urgent and emergency situations

    Wider context from the report

    “1. That doctors should leave messages on answerphones for patients to make contact with them in urgent and emergency situations. ”

    Source location

    Ms Ivanika Olivari · Prevention of Future Deaths report
    Page 3 · 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

    Review ethical guidance and identify any necessary amendments clarifying that urgent messages may be left for patients.

    Verbatim wording from the response

    “• The GMC considers its guidance for doctors and amend where necessary to ensure that it is clear that messages may be left for patients in urgent and emergency situations.”

    Source location

    2018-0073-Response-by-General-Medical-Council
    Page 1 · response
    Published 16 June 2018

    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

    Alert the Information Governance Alliance to the absence of NHS guidance on voicemail use.

    Verbatim wording from the response

    “We will also alert the Information Governance Alliance (which is the authoritative source of advice and guidance about the rules on using and sharing information in health and care in England) to the absence of guidance for NHS staff on the use of voicemail.”

    Source location

    2018-0073-Response-by-General-Medical-Council
    Page 2 · response
    Published 16 June 2018

    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

    Amend Appendix 1 guidance to require appropriate callback messages and alternative contact attempts in urgent or emergency situations while protecting patient confidentiality.

    Verbatim wording from the response

    “However, in light of the concerns you raised in the PFD report, we have made immediate changes to the guidance in Appendix 1 relating to leaving telephone messages, as follows:”

    Source location

    2018-0073-Response-by-St-Georges-University-Hospital-NHS-Trust
    Page 2 · response
    Published 16 June 2018

    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

    Specific procedural advice on voicemail decisions and contents is outside the remit of general GMC guidance.

    Verbatim wording from the response

    “Given the nature and remit of our guidance, we do not give further procedural advice on what specific steps doctors should take when weighing up whether to leave a voicemail message, or what its contents should be. However the guidance is clear that while confidentiality is an important and legal duty it is not absolute and the safety of patients must be taken into account. In line with the general approach in the guidance, a decision not to leave a message would need to be balanced against the harm (or lack of benefit) to the patient in delaying communication and perhaps further treatment as a consequence.”

    Source location

    2018-0073-Response-by-General-Medical-Council
    Page 2 · response
    Published 16 June 2018

    Open published response
  9. Bedfordshire and Luton

    AI-generated summary

    MAVIS JEANNE REVES · 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

    On 1 July 2017, Mavis Jeanne Reves pulled her Careline cord because she had a dry mouth and was struggling to breathe. Paramedics reached her flat after delays involving the building’s automated entry system and key safe, and performed CPR. The concerns included limitations of the analogue Careline system, delays in emergency access and connection time, and difficulties identifying the master key.

    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 the analogue Careline system to support concurrent emergency access and calls

    Wider context from the report

    “(1) At the Inquest it was revealed that there are 4 ways a non-resident can enter the building: (a) By entering the room number on the keypad (b) By using a code (c) By pressing 2 buttons, namely “clear” and then “call” (d) By being allowed in by a resident that was passing through the entrance The deceased did not answer the call; the code was not available to the paramedic, who had arrived before it was forwarded to his car’s computer. In any event that which arrived was probably not the correct code. The “call” button is supposed to connect to the Emergency Call Centre, but will not connect if the Careline has been pulled. In this case, the fact that the deceased was still talking to the Careline Operator meant that option (c) above was not available to the paramedic. This is because the system in place is an analogue system and there is only one line going from the building to Careline. Evidence was heard that only 3% of Careline calls result in 999 being called. The remaining 97% are non-urgent calls, accidental calls and calls by residents who are lonely. This means that access using option (c) could be deprived by anyone else in the building using the system. Further it means that once one resident is using the system that no other resident can call the Careline, even if there is an emergency. The scenario of a resident calling the Careline in an emergency and staying on the line is understandable and cannot be that unusual. It appears that a digital system would avoid these problems. It is understood that for a digital system to be installed the residents must agree to fund it, and that would then form part of the service charge. My concern is twofold. First, do the residents know of the limitation within the Careline System currently installed? Secondly, in the absence of an upgrade to digital, plans need to be put in place so that the emergency services can gain access without undue delay. (2) The Inquest heard that the analogue system takes 90 seconds to connect. The reason for this is because it is also sending data relating to the Careline Operator’s Terminal. A digital system would reduce that to 4 seconds. My concern again is whether the residents know this. In cases where promptness is important 90 seconds can be the difference between life and death. ”

    Source location

    MAVIS JEANNE REVES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Central Hampshire

    AI-generated summary

    Sean Patrick Plumstead · 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

    Sean Plumstead, a convicted prisoner at HM Prison Winchester, died on 18 September 2016 after being found hanging by a ligature in his cell and later having treatment withdrawn following severe brain injury. The report raised concerns about inadequate suicide and self-harm awareness training for prison and prisoner-facing staff, unclear responsibility for training Carillion staff, and delayed responses to emergency cell bells.

    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 an alternative means for prisoners to request emergency assistance

    Wider context from the report

    “3. Emergency Cell Bells The emergency cell bell (ECB) in Mr Plumstead’s cell had been activated by his cellmate but the response to this took 10.5 minutes whereas the expected response time is 5 minutes. The evidence showed that there was and continues to be widespread misuse of ECB’s by prisoners particularly those on general wings, which leads to prison officers responding on occasions over an hour after the ECB has been activated. There are only limited sanctions available for enforcement of the proper use of the system by prisoners. The system allows no means of prioritising calls or identifying the time when the ECB has been pressed. Prisoners who have a genuine emergency have no alternative means of requesting assistance and therefore the risk is that there medical emergencies will not have a timely response and further deaths in such circumstances will occur. The current system is not fit for purpose and notices to prisoners are ineffective. ”

    Source location

    Sean Patrick Plumstead · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026