Recurring concern

Unreliable security alarms for detecting insecure exits and access

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First reported 22 Feb 2017•Latest report 31 Jul 2017

Definition

What this concern includes

Includes failures of dedicated security-alarm controls for detecting compromised doors, exits or access points and alerting the responsible staff or security function, including alarm design, coverage, activation, audibility, monitoring and response arrangements where these directly concern insecure access or exits.

Not included

  • Excludes generic fire-detection, patient-monitoring, bed, call-bell or clinical alarms unless the assertion specifically concerns detecting insecure access or exits.
  • Excludes general perimeter fencing, door design or access-control deficiencies where no security-alarm failure is identified.
  • Excludes failures occurring after a security alarm has been reliably received when the alarm system itself was not deficient.
  • Excludes generic staffing, communication or response deficiencies that are not directly tied to the security-alarm process.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2017–2017

First to latest report issue date

Stated actions
3

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.

Care Quality Commission1
Harbour Healthcare Ltd.1
Rail Safety and Standards Board1
Stockport NHS Foundation Trust1
Transport for West Midlands1
West Midlands Fire Service1
Wolverhampton City Council1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Michael Bingham · 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 Bingham fell down stairs at Hilltop Court Care Home on 22 September 2016 after an emergency door release caused internal secure doors to open. He sustained C1/C2 fractures, was not diagnosed with a CT scan, later developed aspiration pneumonia, and died on 24 September 2016; concerns included door security alarms, guidance and inspection procedures, clarity about CT scans for older people with cognitive impairment, and the resulting risk of further deaths.

    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 provide alarms indicating when internal secure doors become insecure across the service

    Wider context from the report

    “It was accepted by you during the inquest that there was a ‘blind spot’ in the risk assessment of the internal secure doors, in that you were not required by any regulatory body to have an alarm to alert staff when secure doors became insecure by virtue of the use of the green emergency door release or otherwise. I accept that you have now implemented an alarm system in Hilltop Court Care home that will indicate when the internal doors become insecure and have fitted auditory alarms in relation to the external doors. You indicated that you are in the process of implementing similar systems in the other care homes owned by Harbour Healthcare. I am concerned that without the implementation of these alarms across your service provision there would continue to be circumstances that create a risk of other deaths. I would be grateful for an indication of when you expect this implementation to be completed by way of response. ”

    Source location

    Michael Bingham · 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

    Install screech alarms or key-box panels on internal emergency doors and link them to nurse emergency call systems at Hilltop Court.

    Verbatim wording from the response

    “I can confirm, as you indicated in your report, that the work to the internal doors at Hilltop Court have been completed, and that either screech alarms or key box panels have been installed. These mechanisms are also linked to the internal nurse emergency call system so the staff will be alerted should one of the internal doors be opened via the emergency release mechanism.”

    Source location

    2017-0322-Responses
    Page 1 · response
    Published 3 December 2017

    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

    Complete screech-alarm installation across other care homes, with Bentley Manor Nursing Home scheduled for completion by 31 August 2017.

    Verbatim wording from the response

    “I can confirm that the work to fit screech alarms to all internal emergency exit doors has been completed in all of Harbour Healthcare’s other care homes with the exception of Bentley Manor Nursing Home in Crewe, which will be completed by August 31st 2017.”

    Source location

    2017-0322-Responses
    Page 1 · response
    Published 3 December 2017

    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

    Undertake further inspections to verify internal-door alarms or key-box panels at Hilltop Court and screech-alarm installation across Harbour Healthcare locations.

    Verbatim wording from the response

    “The registered provider Harbour Healthcare has copied CQC into correspondence sent to yourself confirming the action they have taken following the death of Mr Bingham and the additional action they have taken in response to your Regulation 28 Report.”

    Source location

    2017-0322-Responses
    Page 9 · response
    Published 3 December 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

    Providers or registered managers, rather than the regulator, decide how to comply with regulations and manage day-to-day safety work.

    Verbatim wording from the response

    “In doing all of this we must however have regard to the fact that as with most regulators (and in accordance with our regulatory remit) CQC highlights breaches of the regulations to a Provider and requires compliance, but does not tell them how they”

    Source location

    2017-0322-Responses
    Page 7 · response
    Published 3 December 2017

    Open published response

  2. North London

    AI-generated summary

    George Henry Dicker · 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

    George Henry Dicker entered the railway tracks and electrical lines at Woodside Park Underground Station on 9 May 2016, where he likely died after contact with the live rail and being struck by a train. The substantive concern was that there was no alarm or warning to the signaller when a person passed through the gate onto the tracks.

    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 alarm or warning to the signaller when a person passes through the gate to the tracks at the end of the platform

    Wider context from the report

    “That there is no alarm or warning to the signaller that a person has passed through the gate to the tracks at the end of the platform. ”

    Source location

    George Henry Dicker · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Black Country

    AI-generated summary

    Mr Christopher Brookes · 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 Christopher Brookes, aged 22, fell around 40 feet from a gate at Wolverhampton bus station after leaving through a fire exit and died from his injuries on 29 October 2017. The inquest heard that there had been a similar previous incident at the same location and that security guards failed to attend when an alarm indicated unauthorised use of the fire exit.

    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 security guards to attend alarms indicating unauthorised use of the fire exit

    Wider context from the report

    “2. Evidence also emerged during the inquest that an alarm would be activated if the fire exit was used. It appears that security guards employed to deal with unauthorised use of the fire exit failed to attend. ”

    Source location

    Mr Christopher Brookes · 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

    The Council lacks control over the bus station fire escape door and the security arrangements for the relevant area.

    Verbatim wording from the response

    “2. With regard to the alarm being activated, as you may be aware from the evidence given at the Inquest itself, the fire escape door from the bus station is not something under the control or operation of City of Wolverhampton Council. The combined transport executive has responsibility for and control over the bus station operation, including the fire escape door from the bus station itself. In addition, the security services contracted to deal with that element of the operations is something entirely under the control and responsibility of the combined transport executive. The Council has no control over the provision of security for the relevant area.”

    Source location

    2018-0055-Response-by-City-of-Wolverhampton
    Page 1 · response
    Published 8 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

    Responsibility for operating the bus station, including its fire escape door and security services, rests with the combined transport executive.

    Verbatim wording from the response

    “2. With regard to the alarm being activated, as you may be aware from the evidence given at the Inquest itself, the fire escape door from the bus station is not something under the control or operation of City of Wolverhampton Council. The combined transport executive has responsibility for and control over the bus station operation, including the fire escape door from the bus station itself. In addition, the security services contracted to deal with that element of the operations is something entirely under the control and responsibility of the combined transport executive. The Council has no control over the provision of security for the relevant area.”

    Source location

    2018-0055-Response-by-City-of-Wolverhampton
    Page 1 · response
    Published 8 June 2018

    Open published response
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Data last updated 7 September 2026