Recurring concern

Failure of emergency alarm response

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First reported 16 Sep 2015•Latest report 23 Mar 2026

Definition

What this concern includes

Includes failures of the dedicated emergency alarm response system, including delayed or absent alarm activation and delayed or absent staff response to an activated emergency alarm.

Not included

  • Excludes general delays in emergency care that are not specifically connected to an emergency alarm.
  • Excludes failures of other communication, escalation or alerting processes unless they concern the dedicated emergency alarm response system.
  • Excludes the particular reason for delay, such as assuming an alarm is behavioural or false, when the broader alarm-response failure is the supported concern.
Reports
22

Distinct published reports

Individual concerns
24

A report can raise multiple concerns

Date range
2015–2026

First to latest report issue date

Stated actions
30

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.

HM Prison and Probation Service3
Department of Health and Social Care2
Office of Rail and Road2
Aspray House1
British Heart Foundation1
Broadland View Care Home1
Brunswick Gardens Village1
Care Quality Commission1
Carillion (AMBS) Limited1
Coed Duon1
CSS Telecare Service1
Cygnet Behavioural Health Limited1
Docklands Light Railway Limited1
DW Fitness First1
East London NHS Foundation Trust1

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. Lincolnshire

    AI-generated summary

    Carlington Maurice Spencer · 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

    Carlington Maurice Spencer, a detainee at Morton Hall IRC, suffered a right middle cerebral artery infarction after being found unwell and was later confirmed deceased on 3 October 2017. The report identifies concerns about confirmation bias relating to presumed drug use, inadequate monitoring and record keeping, poor communication and escalation between discipline and healthcare staff, failures to recognise stroke symptoms, and delays in emergency treatment.

    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

    Confusion and uncertainty over emergency alarm activation

    Wider context from the report

    “3. In this case, a "general alarm" was called and in evidence from both Discipline and Healthcare staff, there exists on-going confusion and uncertainty as to the calling of a general alarm or a "Code 1" or "Code 2" alarm or "Code Red" or "Code Blue" (the replacement codification) confirming the need for training or re-training on this issue. ”

    Source location

    Carlington Maurice Spencer · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report
  2. Inner North London

    AI-generated summary

    Flora Shen · 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

    Flora Shen died on 6 January 2020 at Lime House station after falling from the platform and being struck by a train. The report raised concerns about the reliance on members of the public to notice hazards and activate alarms, and about limited CCTV coverage and the response process on the driverless DLR 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

    Dependence on multiple manual actions to activate the emergency brake

    Wider context from the report

    “(1) If a member of the public on the train sees a person or hazard on the track ahead they have to go to one of the doorways to activate the passenger alarm. The Passenger Services Assistant then goes to the telephone which is accessed by a key to ask why the passenger alarm has been activated. In order to stop the train the Passenger Services Agent then needs to replace the phone, lock the phone compartment and use a key to activate the emergency brake. ”

    Source location

    Flora Shen · Prevention of Future Deaths report
    Page 1 · 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

    Dependence on members of the public to notice hazards and activate alarms

    Wider context from the report

    “(3) The central DLR CCTV monitoring system cannot watch all stations at the same time and the safety of persons slipping, falling or collapsing on to a line on the DLR system seems to rely on ability of members of the public to notice the hazard and activate the alarm on either the platform or the train. ”

    Source location

    Flora Shen · 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

    Challenge DLR on the reasonable practicability of providing additional emergency stop facilities throughout the vehicles.

    Verbatim wording from the response

    “ORR has challenged DLR on the reasonable practicability of providing emergency stop facilities within all the vehicles on the system. DLR have advised us that the vehicles already have 10 locations where a member of staff can activate an emergency brake application. Two of these are within the manual driving panels at each end of the vehicle and the other eight are located one at each doorway and activated by the member of staff inserting their key. This does appear to give a reasonable level of access to staff. Experience in mainline trains suggests that providing passengers with means to stop trains can lead to misuse, which in turn can create different risks; including significant disruption to networks, overcrowding on trains, and ultimately passengers self-detraining from stalled trains with all the risk this brings.”

    Source location

    2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
    Page 2 · response
    Published 11 June 2020

    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

    Discuss with DLR the reasonable practicability of technological solutions to detect people on the track and stop approaching vehicles.

    Verbatim wording from the response

    “ORR has discussed with DLR the reasonable practicability of providing further technological solutions that could detect persons on the track and take action to stop approaching vehicles. DLR have advised us that they have investigated the availability of such technologies and are currently seeking a partner to conduct a study into potential on-train obstacle detection systems. It is clear that DLR is keeping this topic under review and actively seeking solutions.”

    Source location

    2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
    Page 3 · response
    Published 11 June 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and roll out enhanced platform-alarm signage to improve passengers’ ability to locate alarms.

    Verbatim wording from the response

    “1. Enhancing the signage on the platform alarms – the intention of this work is to give passengers a greater chance of locating the alarms on the platforms should they notify a hazard on the track. The timescale for completion is July 2021; the programme is now being developed and would be rolled out on a risk-basis.”

    Source location

    2020-0115-Response-from-TFL_Redacted.pdf
    Page 6 · response
    Published 11 June 2020

    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

    Research and collaborate on CCTV and train-based hazard-detection technologies, including assessing potential options for a DLR trial.

    Verbatim wording from the response

    “2. We will continue to research and collaborate with suppliers to identify potential solutions and improvements in the area of hazard/obstacle detection. We are currently exploring an emerging CCTV product that can detect persons and/or objects on the track, and have held preliminary discussions with its developer to assess its potential for testing on the DLR. We should know by December 2020 if a trial can be taken forward. However, this is partly dependent on the existing CCTV network being capable of supporting such a trial.”

    Source location

    2020-0115-Response-from-TFL_Redacted.pdf
    Page 6 · response
    Published 11 June 2020

    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

    Passenger-activated train stops could cause misuse, network disruption, overcrowding and unsafe self-detraining, creating greater risks than they solve.

    Verbatim wording from the response

    “ORR has challenged DLR on the reasonable practicability of providing emergency stop facilities within all the vehicles on the system. DLR have advised us that the vehicles already have 10 locations where a member of staff can activate an emergency brake application. Two of these are within the manual driving panels at each end of the vehicle and the other eight are located one at each doorway and activated by the member of staff inserting their key. This does appear to give a reasonable level of access to staff. Experience in mainline trains suggests that providing passengers with means to stop trains can lead to misuse, which in turn can create different risks; including significant disruption to networks, overcrowding on trains, and ultimately passengers self-detraining from stalled trains with all the risk this brings.”

    Source location

    2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
    Page 2 · response
    Published 11 June 2020

    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

    On-train and CCTV obstacle-detection technology is considered insufficiently mature for reliable operation on the DLR network.

    Verbatim wording from the response

    “2. We will continue to research and collaborate with suppliers to identify potential solutions and improvements in the area of hazard/obstacle detection. We are currently exploring an emerging CCTV product that can detect persons and/or objects on the track, and have held preliminary discussions with its developer to assess its potential for testing on the DLR. We should know by December 2020 if a trial can be taken forward. However, this is partly dependent on the existing CCTV network being capable of supporting such a trial.”

    Source location

    2020-0115-Response-from-TFL_Redacted.pdf
    Page 6 · response
    Published 11 June 2020

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing risk controls were considered appropriate and reasonably practicable, so additional platform screen doors were not required.

    Verbatim wording from the response

    “ORR has confirmed that the risk assessments jointly undertaken by DLR and KAD include for the events of a person falling or jumping onto the track and the consequent potential events. This assessment identifies a range of control and mitigation measures for these events. These include, amongst other things, the alarm points on stations and random CCTV monitoring, and station signage, platform markings and surface finish. Measures also include wider initiatives such as proactive liaison with local police and mental health services.”

    Source location

    2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
    Page 2 · response
    Published 11 June 2020

    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

    Reliable commercial technologies for detecting people on tracks and stopping trains were not yet available off the shelf.

    Verbatim wording from the response

    “ORR has discussed with DLR the reasonable practicability of providing further technological solutions that could detect persons on the track and take action to stop approaching vehicles. DLR have advised us that they have investigated the availability of such technologies and are currently seeking a partner to conduct a study into potential on-train obstacle detection systems. It is clear that DLR is keeping this topic under review and actively seeking solutions.”

    Source location

    2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
    Page 3 · response
    Published 11 June 2020

    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

    DLR, KAD and TfL held responsibility and power to investigate and implement additional technological or operational safety solutions.

    Verbatim wording from the response

    “It is for these reasons that ORR considers that the concerns in the Coroner’s report would be better directed to DLR, KAD and TfL. These organisations hold the responsibility for health and safety and have the power to investigate and implement additional or alternative new technological and operational solutions that could reduce further the risks to persons on the track.”

    Source location

    2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
    Page 3 · response
    Published 11 June 2020

    Open published response
  3. 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
  4. North Wales (East and Central)

    AI-generated summary

    Kathleen Smith · 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

    Kathleen Smith, who had advanced dementia and was at risk of choking, died after being fed unsuitable food and aspirating. The report raised concerns about inadequate staff training, failure to assist during the choking emergency, poor communication, and insufficient management oversight of safe food and fluid care.

    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 intervene when an internal emergency alarm indicates assistance is needed

    Wider context from the report

    “1. Staff were not sufficiently trained in first aid or how to assist a resident who was at risk of choking. 2. Staff did not intervene to assist the resident for whom the internal emergency alarm had been sounded as help was needed. 3. Staff were not sufficiently trained in how to select and prepare correct foods and fluids for residents with special dietary needs and who had a documented risk of choking. 4. The above training remains incomplete approximately 11 months after the death of Mrs Smith. 5. Staff could not demonstrate they understood how to deliver safe care and treatment regarding food and fluids and manage the risk of choking. 6. There is no adequate management oversight to ensure staff are appropriately deployed to those residents at risk of choking and or who require one to one assistance with food and fluids. ”

    Source location

    Kathleen Smith · 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

    Two staff members responded to the emergency call and there was no sign that the resident was in distress.

    Verbatim wording from the response

    “2. On the day in question, I must once again stress that two members of staff answered the emergency nurse call bell, one was the duty RGN and the other a senior carer, they did intervene and carer remained with her until she passed away, there was no sign she was in distress.”

    Source location

    2019-0184-Response-by-Coed-Duon-Care-Home
    Page 2 · response
    Published 14 August 2019

    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
  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 the alarm-response process to provide trained responders with the nature of the emergency

    Wider context from the report

    “5. The panic button alarm was audible by a beeping sound in reception and a light was illuminated on a control panel there, but this relied solely on the reactions of one individual who was not necessarily first aid trained and, if the receptionist did call 999, s/he would not necessarily know the nature of the emergency. In this instance, the receptionist who called an ambulance did not know that Mr Al-Hirsi had suffered a cardiac arrest. ”

    Source location

    Kamal Yahyia AL-HIRSI · 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

    Failure of panic-button alarms to alert staff throughout the building

    Wider context from the report

    “4. Some members of staff did not know the exact location of the panic buttons, nor the circumstances in which they should be pressed. The panic buttons did not sound 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. It did not occur to the cleaner who first realised that Mr Al-Hirsi was in difficulty to press the alarm, but even if she had, this would not have brought other staff running to help. ”

    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

    Upskill designated first aiders to obtain pool responder qualifications.

    Verbatim wording from the response

    “It is also the Company’s intention to upskill its designated first aiders to have a pool responder qualification. We will endeavour to complete this by 31 December 2018.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 1 · 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 and conduct regular documented drills covering multiple emergencies.

    Verbatim wording from the response

    “As noted above, the Company requires all of its new and existing employees to undertake a documented Workplace Induction Checklist, where they will be given a guided tour of their site to ensure that they are aware of the location and use of the building’s emergency and life saving apparatus. The Company will also review its Emergency Action Procedures (“EAP”) and ensure that its employees participate in regular documented drills. The Company’s new Health & Safety Compliance Manager will audit these centrally on a quarterly basis from 1 October 2018.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 2 · 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

    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
  7. London (West)

    AI-generated summary

    John Kevin O’MEARA · 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

    John Kevin O’MEARA suffered respiratory failure and died on 29 March 2016 in a cell at HM Prison Wormwood Scrubs. The report identifies insufficient staffing, inadequate medical monitoring, and a missed opportunity to raise concerns about his health. It also raises concerns about delays in activating emergency codes and the availability of trained passive dogs to help control novel psychoactive substances in prisons.

    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 immediately activate the Code Blue/Red system

    Wider context from the report

    “Activation of Code Blue/Red The sad facts leading up to the death of John Kevin O’MEARA have not been the first set of facts where I have heard about a death where the activation of codes has not been immediate. I am concerned that Prison Officers are not strictly following the Code Blue/Red system which is meaning there is a delay in the London Ambulance being called. Whilst I can see in many cases that, by the time the prisoner has been found, there may be nothing that can be done to resuscitate them with the number of deaths happening relating to opiate use, the prompt administration of Naloxone is important to give the deceased the best chance; and this is only one responsive measure. I gather the current way that Officers are trained is by the use of Notices and Pocket-sized Cards. The Officer finding Mr O’Meara, even after questioning by myself and the Counsel for Interested Persons, left the witness stand still not understanding that by not immediately calling a Code Blue, and despite prison medical staff coming quickly, an ambulance would not have been called. Even presumably having reflected on the case, she did not appear to understand the reason why a Code is called. I am asking for more consideration to be given to ensure the right message is getting across and that Prison Officers understand the importance of and reasons for the use of the codes. ”

    Source location

    John Kevin O’MEARA · 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

    Publish notices, display signs, include emergency procedures in induction, and attach notices to First Night Centre cell doors.

    Verbatim wording from the response

    “Your first concern is with the failure immediately to use an emergency response code, something that has also occurred in other cases. I understand that you heard evidence about a variety of steps that are being taken locally to ensure that staff are aware of the importance of using the correct emergency code. Regular notices to staff are published, signs are displayed in all offices and information about emergency response procedures is included in the induction for all new staff. More recently, notices have been attached to all cell doors in the First Night Centre, and early indications are that staff have found this useful. Plans are in place to extend this”

    Source location

    2018-0012-Response-by-HM-Prison-and-Probation-Service
    Page 1 · response
    Published 7 March 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

    Extend cell-door emergency-code notices to healthcare, segregation, and detox areas.

    Verbatim wording from the response

    “Your first concern is with the failure immediately to use an emergency response code, something that has also occurred in other cases. I understand that you heard evidence about a variety of steps that are being taken locally to ensure that staff are aware of the importance of using the correct emergency code. Regular notices to staff are published, signs are displayed in all offices and information about emergency response procedures is included in the induction for all new staff. More recently, notices have been attached to all cell doors in the First Night Centre, and early indications are that staff have found this useful. Plans are in place to extend this”

    Source location

    2018-0012-Response-by-HM-Prison-and-Probation-Service
    Page 1 · response
    Published 7 March 2018

    Open published response
  8. 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

    Delays in responding to emergency cell bell activations

    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

    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

    Issue staff notices requiring prompt responses to emergency cell bells.

    Verbatim wording from the response

    “All staff at Winchester have been issued with individual notices about the importance of answering ECBs promptly within the required time. Prisoners have again been issued with information about the risks caused to themselves and others by misuse of ECBs. In addition, the ECB response times are now checked every day in order to improve accountability, and the Governor is preparing a bid for funding to upgrade the ECB system. The range of sanctions available for prisoners misusing ECBs will increase following the rollout of digital in-cell equipment in 2018, as abuse of the ECB system may result in the removal of this equipment.”

    Source location

    2017-0316-Response-by-HM-Prison-Probation-Services.2-1
    Page 3 · 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

    Check emergency cell bell response times daily to improve accountability.

    Verbatim wording from the response

    “All staff at Winchester have been issued with individual notices about the importance of answering ECBs promptly within the required time. Prisoners have again been issued with information about the risks caused to themselves and others by misuse of ECBs. In addition, the ECB response times are now checked every day in order to improve accountability, and the Governor is preparing a bid for funding to upgrade the ECB system. The range of sanctions available for prisoners misusing ECBs will increase following the rollout of digital in-cell equipment in 2018, as abuse of the ECB system may result in the removal of this equipment.”

    Source location

    2017-0316-Response-by-HM-Prison-Probation-Services.2-1
    Page 3 · 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

    Prepare a funding bid to upgrade the emergency cell bell system.

    Verbatim wording from the response

    “All staff at Winchester have been issued with individual notices about the importance of answering ECBs promptly within the required time. Prisoners have again been issued with information about the risks caused to themselves and others by misuse of ECBs. In addition, the ECB response times are now checked every day in order to improve accountability, and the Governor is preparing a bid for funding to upgrade the ECB system. The range of sanctions available for prisoners misusing ECBs will increase following the rollout of digital in-cell equipment in 2018, as abuse of the ECB system may result in the removal of this equipment.”

    Source location

    2017-0316-Response-by-HM-Prison-Probation-Services.2-1
    Page 3 · 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

    Issue a national staff learning bulletin on prompt emergency cell bell responses and tackling prisoner misuse.

    Verbatim wording from the response

    “At national level a learning bulletin for staff on the importance of responding promptly to ECBs, and tackling abuse of them by prisoners, will be issued early in 2018.”

    Source location

    2017-0316-Response-by-HM-Prison-Probation-Services.2-1
    Page 3 · response
    Published 3 December 2017

    Open published response
  9. Surrey

    AI-generated summary

    Derek Clifford Dudley · 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

    Derek Clifford Dudley was found deceased from hypothermia outside the back door of his home on 6 March 2017, after previously activating his community alarm following a fall. Concerns included the call being ended before he had got up, limited follow-up after a later unanswered call, unsupervised trainee operators, the absence of pro forma questions, and insufficient background information for assessing service users’ needs.

    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 persist in offering and persuading service users to accept help after alarm activation

    Wider context from the report

    “Mr Dudley was only offered an ambulance once during the course of the telephone conversation and no attempt was made to persuade him to accept any help. ”

    Source location

    Derek Clifford Dudley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. 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
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Data last updated 7 September 2026