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. South London

    AI-generated summary

    Ratidzai Kudkawashe SANGARE · 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

    Mrs Ratidzai Kudkawashe Sangare was a detained patient who was found unresponsive on the floor of her room on the morning of her planned discharge, with a dressing gown belt around her neck. The inquest concluded that she died from ligature compression of the neck, between 5.15 and 8.28 a.m. on Millbrook Ward. Concerns included delays in recognising the need for resuscitation and emergency assistance, delayed response to the alarm, and limited telephone access for agency staff.

    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 respond immediately to alarms treated as behavioural issues or false alarms

    Wider context from the report

    “(2) Staff did not respond immediately to alarm when it was activated, on the assumption that it was likely to be a behavioural issue or false alarm rather than a medical emergency ”

    Source location

    Ratidzai Kudkawashe SANGARE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Adil HABIB · 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

    Adil Habib died at HMP Pentonville after swallowing a package containing crack cocaine during a search while subject to control and restraint; he choked on it. The inquest recorded the death as accidental, with acute respiratory failure due to mechanical obstruction of the upper airway by a foreign object. A concern was raised that the 999 caller did not immediately provide the prison gate location for attending paramedics, and that ambulance call-handling systems did not then show alternative gates for all London 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 of Hotel 7 nurses to respond immediately to every emergency alarm

    Wider context from the report

    “The nurse who was on call as Hotel 7 at the prison did not respond to the emergency alarm that was activated at the start of the control & restraint of Mr Habib, as she should have. Instead, she only responded once a Level 1 emergency was radioed. I appreciate that this nurse no longer works at HMP Pentonville and that your team has taken steps to remind all nurses operating as Hotel 7 of their responsibility to respond to every alarm immediately. ”

    Source location

    Adil HABIB · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026