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. Central Hampshire

    AI-generated summary

    Michael Folley · 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

    Michael Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.

    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

    Radio connection delays affecting emergency information relay

    Wider context from the report

    “There was conflicting evidence during inquest about the effectiveness of when the Code Blue call was made and whether this resulted in any delay in the information being passed to the ambulance service. On balance of probabilities, the problem seemed to come from the fact that the custody manager did give the correct callsign but because there is a two second delay when pressing the radio button this may not have been picked up immediately in the control room. This is of significant concern both in respect of the safety prison officers but also the need to obtain medical help for prisoners and suggests the need to update the radio system ”

    Source location

    Michael Folley · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Nasar AHMED · 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

    Nasar died following an anaphylactic reaction contributed to by asthma while he was in the internal exclusion room at school. The concerns included delayed or inappropriate advice about using his adrenaline auto-injector, discrepancies and gaps in asthma and allergy care planning, unsuitable emergency inhaler equipment, inadequate medication review systems, and shortcomings in staff awareness, training and emergency procedures.

    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

    Emergency-services contact procedures causing avoidable delay

    Wider context from the report

    “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

    Source location

    Nasar AHMED · Prevention of Future Deaths report
    Page 12 · concerns

    Open source report

  3. Inner South London

    AI-generated summary

    James O’Brien · 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

    James O’Brien collapsed in his room at Churchill Hospital on the night of 8/9 December 2015 and died at St Thomas’ Hospital on 9 December 2015. Concerns included delays in starting resuscitation, calling an ambulance and bringing the defibrillator, inappropriate defibrillator attachment, inadequate information provided to ambulance services, and failures in staff training, induction and ward familiarity. The inquest concluded that the emergency response by hospital staff was inadequate and that earlier intervention might have made a difference.

    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 raise the emergency alarm

    Wider context from the report

    “(1) There was a failure to press the alarm. ”

    Source location

    James O’Brien · Prevention of Future Deaths report
    Page 1 · 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

    Establish local emergency-response and alarm protocols covering escalation, responder responsibilities and radio use.

    Verbatim wording from the response

    “3. Responding to Emergencies – all staff are required to undertake the on-line training provided by Cambian Adult Services on responding to emergencies.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 3 · response
    Published 24 March 2017

    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 former operator no longer controls future hospital safety steps, which fall to the successor operator.

    Verbatim wording from the response

    “The Churchill Hospital was at the date of Mr O’Brien’s death operated by Cambian Healthcare Limited which was then part of our Group. However, in December 2016 we sold our adult services division, including Cambian Healthcare Limited. The Group, therefore, no longer has any executive responsibility in relation to the hospital. Cambian Healthcare Limited is now a subsidiary of Cygnet Healthcare Limited and its Chief Executive Officer is Dr Tony Romero.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 1 · response
    Published 24 March 2017

    Open published response

  4. Liverpool and the Wirral

    AI-generated summary

    Mark LILLIOTT · 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

    Mark LILLIOTT, a 54-year-old inmate at HMP Liverpool, was found unresponsive in his cell on the morning after 22 December 2014 and was pronounced dead at 09:12. The report raised a concern about a short delay in accessing a senior officer with a radio to request emergency assistance, although it stated that Mr LILLIOTT was already dead when discovered and that the delay did not affect the outcome in this case.

    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 immediate access to a radio for emergency calls

    Wider context from the report

    “When the two Prison Officers discovered Mr Lilliott they immediately tried to identify an Officer with a radio to request immediate assistance from HOTEL1 (the urgent nursing response within the prison) and subsequently determining that this was a CODE Blue and therefore an emergency ambulance was also required. The two Prison Officers therefore left the cell to seek the Senior Officer with the radio. It was reportedly noisy on the wing at the time. The Prison Officers tried to shout down from level 5 to attract the Senior Officer who they believed was on level 2 but this action was unsuccessful. One of the Prison Officers therefore left the 5’s landing to go down to the lower levels and find the Senior Officer, as he passed through level 4 he saw another Prison Officer who he thought might have a radio but he didn’t and therefore he proceeded to lean over the landing and shout again to try to attract the attention of the Senior Officer with a radio and again it was reported that the Prison Officers shouts were not heard because of the noise, it was a busy period with prisoners making their way to their daily activity. When the Prison Officer shouted again to get the attention of the Senior Officer he was on this occasion heard and the appropriate radio dispatches were immediately made in respect of HOTEL1 and Code Blue. The delay, albeit relatively short, in accessing a Senior Officer in possession of a radio on this occasion did not affect the outcome, Mr Lilliott was already dead when he was discovered and had been for some time. However, it might not have been the case that the prisoner was already deceased and it might have been the case and it might be the case in the future that the fastest possible response and action to radio for emergency help could make a difference to the outcome. ”

    Source location

    Mark LILLIOTT · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Dorset

    AI-generated summary

    Liam Day · 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

    Liam Day left home to go climbing on 15 June 2016 and failed to return; his body was recovered from the water on 28 June 2016, with the cause of death given as hypothermia following a fall into the sea. The report raised concerns about his lack of safety equipment, warm clothing, means of seeking help and specific plans, and highlighted the dangers of cold coastal water to people participating in water-based climbing activities.

    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 means to request help during climbing over deep water

    Wider context from the report

    “Liam Day was an experienced climber. He appears to have become interested in a relatively new climbing phenomenon of Deep Water Soloing (DWS). There are inherent risks of falling when climbing and it appears that the view held by those pursuing DWS is that by climbing over deep water you will reduce the risks of seriously injuring yourself should you fall. This is true of the deceased as there was no trauma found to his body on examination. I found the following preliminary issues contributed to his death:- 1. He was climbing with no safety line 2. He was not wearing a lifejacket or buoyancy aid 3. He was not wearing clothing that offered no warmth in the water 4. He was not on his own 5. He had no means of requesting help such as a whistle, a waterproof phone or waterproof marine VHF radio 6. He had left no specific instructions as to where he was intending to climb and what time he would be home The main issue I wish to highlight are the dangerously low temperatures in coastal waters to those enjoying sports/pastimes/hobbies and who are unaware of the same. This is the reason I am including the RYA in this report. During the course of the inquest evidence was given that the sea temperature on 15/6/16 was around 12-13 degrees Celsius. The deeper one descends into water the colder one gets. The surface of the water is cooled by sea breeze. This temperature is in stark contrast to the air temperature found above the water and to the core body temperature of someone carrying out physical activity above the deep water. The consequence of someone falling into deep water who is unprepared for such an eventuality is panic, shortness of breath. Individuals can experience Cold Water Shock Syndrome. The pathologist in this case explained how in a relatively short period of time (taking into account the presence of all factors detailed above) he died as a result of hypothermia. It is the speed with which one can succumb to such a condition that I wish to highlight. ”

    Source location

    Liam Day · 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

    Other members of a climbing party should be nearby to assist, because the guidance's golden rule is never to climb alone.

    Verbatim wording from the response

    “4. A BMC article from 2014 notes one golden rule for deep water soloing, to never go alone. In our updated advice we will ensure that this vital message is brought to the fore.”

    Source location

    2016-0402-Response-by-BMC
    Page 2 · response
    Published 19 February 2017

    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

    Mountaineering falls outside the respondent’s remit, so it does not undertake responsive safety work for that activity.

    Verbatim wording from the response

    “Although the RYA has no remit for mountaineering it seems to us that a lifejacket or buoyancy aid and the sort of clothing that offers warmth in water would present a significant hazard to the wearer while climbing, particularly “Deep Water Soloing”, and in fact increase the likelihood of the wearer falling.”

    Source location

    2016-0402-Response-by-RYA
    Page 1 · response
    Published 19 February 2017

    Open published response

  6. Surrey

    AI-generated summary

    Rebecca Gilbank · 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

    Rebecca Gilbank, a 25-year-old woman with severe myoclonic epilepsy and significant learning difficulties, was found unresponsive in bed at Clareville Lodge during the early hours of 12 May 2015. Staff were unable to obtain an outside telephone line from the office landline and used a personal mobile phone to call emergency services, while CPR was unsuccessful. The principal concerns were that a required 1.30am check had been missed because staff were attending to other service users, and that staff did not know how to obtain an outside line to emergency services, causing a delay of unknown duration.

    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 staff knowledge about obtaining an outside telephone line to emergency services

    Wider context from the report

    “Lack of knowledge about how to obtain an outside telephone line Evidence at the inquest revealed that the staff on duty did not know how to obtain an outside line to emergency services and, after trying, had to rely on a personal mobile phone. This resulted in a delay of unknown duration. ”

    Source location

    Rebecca Gilbank · 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

    Remove the requirement to dial 9 for an outside telephone line.

    Verbatim wording from the response

    “Independence Homes has taken action in relation to this matter. At a meeting on 14 July 2016, at which we considered the evidence provided during the inquest, we immediately sought to rectify the issue of dialling 9 for an outside line from some of our locations. On 26 July 2016 we contacted our telephone provider and we changed our contract so that there is no longer a need to dial 9 to obtain an outside line. This change was communicated to staff verbally, by email on 7 September 2016 and in the Clareville Lodge Communications Book. Please find a copy of the email enclosed.”

    Source location

    2016-0266-Response-by-Independence-Homes
    Page 3 · response
    Published 26 July 2016

    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

    Communicate the changed outside-line procedure to staff verbally, by email and in the communications book.

    Verbatim wording from the response

    “Independence Homes has taken action in relation to this matter. At a meeting on 14 July 2016, at which we considered the evidence provided during the inquest, we immediately sought to rectify the issue of dialling 9 for an outside line from some of our locations. On 26 July 2016 we contacted our telephone provider and we changed our contract so that there is no longer a need to dial 9 to obtain an outside line. This change was communicated to staff verbally, by email on 7 September 2016 and in the Clareville Lodge Communications Book. Please find a copy of the email enclosed.”

    Source location

    2016-0266-Response-by-Independence-Homes
    Page 3 · response
    Published 26 July 2016

    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

    Clear guidance on obtaining an outside telephone line was already provided at the time of the death.

    Verbatim wording from the response

    “I note that, at the time of Ms Gilbank’s death, clear and accessible guidance on how to obtain an outside line was provided. I understand that there was a sign on the noticeboard in the staff office at Clareville Lodge which stated that staff should dial 9 for an outside line.”

    Source location

    2016-0266-Response-by-Independence-Homes
    Page 3 · response
    Published 26 July 2016

    Open published response

  7. Inner North London

    AI-generated summary

    Samuel Rodney Darren BLAIR · 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

    Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.

    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 promptly acknowledge emergency radio calls

    Wider context from the report

    “6. The prison nurse on call for emergencies, call sign Hotel 7, who was called to attend Mr Blair after he had been found hanging, did not acknowledge the radio call for several minutes, despite numerous attempts by prison control. When she finally did acknowledge the emergency, there was a delay of up to approximately 15 minutes before she was at Mr Blair’s side. (I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about a different nurse, but also in the role of Hotel 7, who did not respond to an emergency alarm as soon as it was activated.) ”

    Source location

    Samuel Rodney Darren BLAIR · 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

    Continue working with the healthcare provider to ensure staff understand the steps required when responding to emergency calls.

    Verbatim wording from the response

    “This report also brings to the attention of the Governor the inadequate response of a nurse to the emergency call from the control room. As you point out in your report, the local protocol on action to be taken in response to emergency response codes is well publicised throughout the prison. The prison will continue to work with the healthcare provider to ensure that all staff are aware of the steps that they are required to take when responding to an emergency call.”

    Source location

    2016-0196-Response-by-NOMS
    Page 2 · response
    Published 19 May 2016

    Open published response

  8. Inner West London

    AI-generated summary

    Jacqueline Emma Brown Scott · 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

    Jacqueline Emma Brown Scott was admitted to hospital on 31 March 2015 with worsening shortness of breath and reduced mobility and was treated with a BIPAP machine. The machine was running on battery because of a failed power socket, but this was not recognised before the battery ran out; she died shortly afterwards. Concerns included the machine’s battery warnings and alarms, staff training, ward power provision and the absence of systems to identify power failures.

    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 repair emergency call bells after notification of a fault

    Wider context from the report

    “(vii) The crash bell for bed bay 5 did not work when the emergency arose. However estates management had been notified some days earlier of the broken patient call in the same bay. This was of concern as both emergency bells were on the same circuit and not fixed until 2 April 2014 when by chance the failure of electricity was identified. ”

    Source location

    Jacqueline Emma Brown Scott · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Leicester City and South Leicestershire

    AI-generated summary

    David Granville Oswald Hughes · 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

    David Granville Oswald Hughes was a patient at the Bradgate Unit who was found unresponsive on his bedroom floor at approximately 02:00 on 23 April 2014. The report identified concerns about failures in 15-minute observations, incomplete fluid balance charts, the lack of bedroom call bells, and nursing staff’s understanding of physical illness signs and symptoms.

    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 call bell systems in patient bedrooms

    Wider context from the report

    “3. Patient bedrooms are not fitted with a call bell system. The staff rely on patients being able to leave their bedroom and seek help or be able to shout loudly enough to be heard. Clearly, a patient who is so unwell that they can do neither would not be able to alert staff that assistance was required. ”

    Source location

    David Granville Oswald Hughes · Prevention of Future Deaths report
    Page 1 · 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

    Complete a review of appropriate call-bell options for Mental Health areas.

    Verbatim wording from the response

    “There are currently 6 rooms identified for patients with physical disabilities in that have call bells in Mental Health Acute Inpatient Services. Traditional call bell systems are not appropriate for Mental Health areas (due to the ligature risks they present), which means the Trust does not have call bells fitted to all Mental Health bedroom areas. However, the service is currently completing a review of appropriate options.”

    Source location

    David-Hughes-Response
    Page 3 · response
    Published 9 February 2016

    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

    Conduct an appraisal and feasibility study for appropriate individual-patient call-bell facilities.

    Verbatim wording from the response

    “The service will conduct an appraisal and feasibility study to facilitate appropriate (individual patient) call-bell facilities by 31 July 2016. The preferred options will be presented to the Service Finance and Performance Committee by September 2016 for investment decision.”

    Source location

    David-Hughes-Response
    Page 3 · response
    Published 9 February 2016

    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

    Present preferred call-bell options to the Service Finance and Performance Committee for an investment decision.

    Verbatim wording from the response

    “The service will conduct an appraisal and feasibility study to facilitate appropriate (individual patient) call-bell facilities by 31 July 2016. The preferred options will be presented to the Service Finance and Performance Committee by September 2016 for investment decision.”

    Source location

    David-Hughes-Response
    Page 3 · response
    Published 9 February 2016

    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

    Prioritise admission of patients with physical disabilities or illness to disabled or call-bell-equipped bedrooms.

    Verbatim wording from the response

    “During the interim period, increased observations levels will be set for those patients who present as physically unwell. The frequency of these observations will be agreed within the multi-disciplinary team and adjusted as required by clinical assessment. Bradgate Unit patients presenting with physical disabilities or illness will be prioritised admission into our disabled or call-bell equipped bedrooms.”

    Source location

    David-Hughes-Response
    Page 3 · response
    Published 9 February 2016

    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

    Traditional call-bell systems cannot be fitted throughout mental health bedroom areas because of the ligature risks they present.

    Verbatim wording from the response

    “There are currently 6 rooms identified for patients with physical disabilities in that have call bells in Mental Health Acute Inpatient Services. Traditional call bell systems are not appropriate for Mental Health areas (due to the ligature risks they present), which means the Trust does not have call bells fitted to all Mental Health bedroom areas. However, the service is currently completing a review of appropriate options.”

    Source location

    David-Hughes-Response
    Page 3 · response
    Published 9 February 2016

    Open published response

  10. North West Wales

    AI-generated summary

    Jasmine Ruby Lapsley · 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 19 August 2016, six-year-old Jasmine Lapsley choked on a grape while on holiday in Morfa Nefyn and died at 23.58 hours despite resuscitation efforts. The report identified concerns about gaps in overnight air support, the lack of a reliable Community First Responder rota and communication system, the need for sufficient local responders, and resource planning during seasonal population increases in rural and remote areas.

    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

    Unreliable communication for contacting Community First Responders in remote and/or rural areas

    Wider context from the report

    “(2) There is no effective rota system for Community First Responders to ensure consistent cover these local volunteers who provide essential support for patients in remote and/or rural locations in North West Wales. The method of communicating Community First Responders to attend is mobile telephone although this is by mobile telephone although this is fraught with difficulties in remote and/or rural areas where network coverage can be patchy at best and frequently non existent. WAST should review the systems in place for rostering and contacting Community First Responders to ensure more consistent cover and more reliable communication. ”

    Source location

    Jasmine Ruby Lapsley · 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

    Pilot and roll out hand-held devices to improve communication with Community First Responders.

    Verbatim wording from the response

    “2.2 Pilot hand-held devices to improve WAST's ability to communicate with CFRs.”

    Source location

    2016-0022-Response-by-Welsh-Ambulance-Services-NHS-Trust
    Page 4 · response
    Published 15 January 2016

    Open published response
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Data last updated 7 September 2026