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. Inner North London

    AI-generated summary

    Codrut IEDERAN · 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

    Codrut Iederan died after pushing an unstable wall at a construction site, which collapsed on him. The report raised concerns that the site’s first aider was absent, the remaining workers were not first-aid trained, and some workers did not know how to summon an ambulance.

    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 that workers can summon emergency help

    Wider context from the report

    “I heard at inquest that the site manager for the Anchor and Hope Public House construction was the site first aider, but he was off site at the time of the fatal accident. The remaining four workers were all Romanian non native English speakers, and none was first aid trained. Mr Iederan had the best English of the four, but of course after the accident he was not in a position to help himself. When one of his colleagues tried to call an ambulance, he realised that he did not know the number. He asked a passer by and so no time was lost in this case. However, when I asked him in court if he now knew the number, some eleven months after Mr Iederan’s death, he did not, despite still being employed by Zelltec. I am conscious that many construction sites in London are heavily supported by foreign workers. It seems to me that it would be of great assistance if employers and site managers were to ensure that all members of their workforce were able to summon help in an emergency. In addition to signs (perhaps in languages other than English) with the 999 number displayed clearly, this could be covered in toolbox talks – of course how it is done is of course a matter for you. ”

    Source location

    Codrut IEDERAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. West Yorkshire (West)

    AI-generated summary

    Nicholas Gary Stocks · 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

    Nicholas Gary Stocks was struck and fatally injured by a vehicle after a collision at the junction of Dry Hill Lane and the A635 Barnsley Road in Huddersfield on 27 September 2012. The report raised concerns about damaged and poorly maintained give-way signs and road markings, inadequate reporting and repair systems, highway inspection practices, risk assessment, and coordination between West Yorkshire Police and Kirklees Council.

    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 an appropriately manned emergency reporting route

    Wider context from the report

    “West Yorkshire Police (1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council. I would ask you to review the system presently in place to ensure that all future reports are made and fully reported (2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken. I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out. (3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified. Kirklees Council (1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat. (2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads. (3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council. (4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained. I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future. (5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times (6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public. (7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed. (8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area. 9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane. I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting is required. ”

    Source location

    Nicholas Gary Stocks · 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

    Preload local-authority contact telephone numbers into the Force Communications system for accessible 24/7 reporting.

    Verbatim wording from the response

    “I am currently in liaison with the five local authorities to ensure that the contact details we hold, both email and telephone, will direct the information/report to the correct department to enable an appropriate response. Furthermore, I will ensure that contact telephone numbers for the”

    Source location

    2015-0200-Response-by-West-Yorkshire-Police
    Page 1 · response
    Published 27 May 2015

    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

    Require communications staff to telephone local authorities about urgent safety defects and record the contact, information supplied and estimated attendance on the police log.

    Verbatim wording from the response

    “In addition, where there is an obvious safety risk and the repairs/remedial action is required urgently, contact will be made by communications staff via telephone to the local authority for the area. The operator will endorse on the police log the name of the person they spoke to, the details supplied and the estimated time of arrival indicated by the authority.”

    Source location

    2015-0200-Response-by-West-Yorkshire-Police
    Page 2 · response
    Published 27 May 2015

    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

    Update Force Communications systems with Kirklees Council contact numbers enabling direct 24/7 communication and urgent attendance arrangements.

    Verbatim wording from the response

    “My representative has met with Kirklees Council and can confirm that I now have up to date contact telephone numbers enabling my communications staff to speak to someone directly “24/7”. This has been updated on our Force Communications systems. It has been agreed that if the matter is urgent the authority will attend the scene within an hour. For non urgent cases the matter will be reported via the email system as detailed above.”

    Source location

    2015-0200-Response-by-West-Yorkshire-Police
    Page 2 · response
    Published 27 May 2015

    Open published response

  3. Exeter and Greater Devon

    AI-generated summary

    Hayden Meirion NORTON · 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

    Hayden Meirion NORTON, a prisoner at HMP Dartmoor, became unwell with flank pain on 6 January 2014, suffered cardiac arrest, and died after resuscitation attempts. The report states that he died from a ruptured atherosclerotic abdominal aortic aneurysm. Concerns included a lack of recorded blood-pressure monitoring, no record that he had been informed about screening for aortic aneurysm, and a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code protocol.

    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 an emergency code protocol for calling an ambulance

    Wider context from the report

    “The Deceased was medically assessed whilst an inmate of HMP Albany (now part of HMP Isle of Wight) on 28 September 2006 and known to have extensive and well documented history of high cholesterol, ischaemic heart disease with episodic angina, two previous myocardial infarctions, blood pressure 220/100. But after arrival at HMP Dartmoor on 15 March 2013, (1) there was no record that his blood pressure was monitored; or (2) that he had been informed of a screening test for aortic aneurysm. He died on 6th January 2014 from a ruptured aortic aneurysm at HMP Dartmoor. (3) There was a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code (unlike HMP Exeter) protocol. There was insufficient evidence to say the above were causative of Mr NORTON’s death but there would have been an awareness of possible problems to come. ”

    Source location

    Hayden Meirion NORTON · Prevention of Future Deaths report
    Page 2 · 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

    Responsibility for establishing the prison’s emergency medical response code protocol rests with the Prison Service, specifically HMP Dartmoor’s Governor.

    Verbatim wording from the response

    “3.3. The third of the concerns relates to the HMP Dartmoor service, at the time of this report it is not clear whether the prison have been asked to respond separately or whether the Trust is expected to do so on their behalf. The Trust is awaiting a response from HM Coroner’s office to determine this. For the purposes of this report the third recommendation has been left for HMP Dartmoor Governing Governor Bridie Oaks-Richards to respond to as this is a prison responsibility.”

    Source location

    2015-0137-Response-by-Dorset-Health-Care-NHS-Trust
    Page 2 · response
    Published 13 April 2015

    Open published response

  4. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Michael Holgate · 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 Holgate fell into the water after the narrow boat he was steering collided with the side of Harecastle Tunnel on 20 May 2014. The concerns included the lack of communication facilities in the tunnel, the absence of a requirement for people on board to wear buoyancy aids, the availability of safety helmets, and the safety information provided to tunnel users.

    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 communication means within the tunnel

    Wider context from the report

    “1. There is no means of communication within the tunnel, I accept that mobile phones are not the like work but I would ask the Trust to explore the possibility of a telephone cable and a number of emergency telephones at strategic or regular points within the tunnel. ”

    Source location

    Michael Holgate · 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 the review of practicable in-tunnel communication systems.

    Verbatim wording from the response

    “at the tunnel during its operating hours. We are currently reviewing options to see if there is a reasonably practicable in-tunnel communication system. We have not been able to complete this study due to the complexity of the review by the reply date stipulated in your report, so we will commit to having concluded it by the 31st March 2015.”

    Source location

    2014-0357-Response-by-Canal-River-Trust
    Page 2 · response
    Published 4 August 2014

    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 in-tunnel communication study could not be completed by the requested deadline because of its complexity.

    Verbatim wording from the response

    “at the tunnel during its operating hours. We are currently reviewing options to see if there is a reasonably practicable in-tunnel communication system. We have not been able to complete this study due to the complexity of the review by the reply date stipulated in your report, so we will commit to having concluded it by the 31st March 2015.”

    Source location

    2014-0357-Response-by-Canal-River-Trust
    Page 2 · response
    Published 4 August 2014

    Open published response

  5. West Somerset

    AI-generated summary

    Names not published · 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

    Seven people died when 34 vehicles collided in thick fog on the M5 motorway near Taunton on 4 November 2011; 51 others were injured. The concerns related to preventing vehicles entering areas of severely reduced visibility, detecting and warning of fog, and managing risks from firework displays that may increase fog or smoke near highways.

    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 immediate communication access to emergency services during firework displays

    Wider context from the report

    ““B” To consider whether or not risks arising from firework displays being held in periods of very high humidity can be greatly reduced if the City and Guild’s courses for Firers and Senior Firers (being the only persons able to conduct a firework display using class IV fireworks) had instruction in realising when such risks arose. AND before operating any display Firers had prepared :- (i) a risk assessment which took account of the topography of the area, nearby watercourses, prevailing wind conditions, identifying highways and all other matters relevant for the safety of the users thereof onlookers and nearby residents. (ii) Assessed the humidity, wind direction and speed immediately before the display, (iii) Positioned lookouts to see if any smoke or fog was approaching a highway or railway line in the immediate vicinity. (iv) Had immediate access to a communication link to the emergency services and (v) Be able to stop the display immediately if an emergency arises AND to consider whether Firers and Senior Firers should be licensed by law for periods of five year AND whether Local Licensing Authorities shall advise persons holding firework displays of the risks referred to herein. ”

    Source location

    Names not published · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. Manchester West

    AI-generated summary

    Katie Louise Davies · 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

    Katie Louise Davies died in hospital on 26 December 2012 after developing Cerebral Venous Sinus Thrombosis and suffering a cardiac arrest. The report raised concerns about blind spots in hospital bleeper systems delaying clinicians’ responses and about differing policies for managing and transferring patients with Cerebral Venous Thrombosis to regional neuroscience centres.

    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 hospital bleeper systems to provide coverage throughout all hospital precincts

    Wider context from the report

    “In the course of investigations at the Royal Albert Edward Infirmary, Wigan, in relation to the failure of Doctors to respond to contact by use of the internal bleeper system during the deceased’s admission, it was discovered that there were two blind or blank spots within the precincts of the Hospital, where bleepers could not be activated. The blind or blank spots were previously unknown but were rectified so that bleepers can now be activated within all precincts of the Hospital. Evidence was given that it is believed that similar problems may exist at other Hospitals in the United Kingdom and Hospitals may be unaware of the existence of blind or blank spots within the Hospital. I have concerns that if blind or blank spots exist within Hospitals that there would be a delay in the response of Clinicians to emergencies and patients requiring urgent treatment and in my opinion there is a risk that future deaths will occur unless action is taken. ”

    Source location

    Katie Louise Davies · 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

    Ask that devolved nations be included in the safety alert about potential pager and bleeper blind spots.

    Verbatim wording from the response

    “We have talked to colleagues in NHS Estates and Facilities about this. They have agreed that a safety alert will be sent to all Trusts in England making them aware of the concerns that you have raised about potential blind spots, and asking them to investigate and take action where necessary. We will also ask that the devolved nations are included in this alert, although you will appreciate that we are not responsible for the NHS outside England.”

    Source location

    2014-0255-Response-by-Department-of-Health
    Page 2 · response
    Published 6 June 2014

    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

    Individual trusts are responsible for their own technology, protocols and operations; the Department lacks a command-and-control function.

    Verbatim wording from the response

    “It may be useful for me to explain that individual Trusts are responsible for their own operations and the Department of Health does not have a “command and control” function.”

    Source location

    2014-0255-Response-by-Department-of-Health
    Page 1 · response
    Published 6 June 2014

    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

    Responsibility does not extend to NHS services outside England, although the concerns will be shared with devolved nations.

    Verbatim wording from the response

    “We have talked to colleagues in NHS Estates and Facilities about this. They have agreed that a safety alert will be sent to all Trusts in England making them aware of the concerns that you have raised about potential blind spots, and asking them to investigate and take action where necessary. We will also ask that the devolved nations are included in this alert, although you will appreciate that we are not responsible for the NHS outside England.”

    Source location

    2014-0255-Response-by-Department-of-Health
    Page 2 · response
    Published 6 June 2014

    Open published response
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Data last updated 7 September 2026