Recurring concern
Failure of emergency alarm response
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Request correctionFirst reported 16 Sep 2015•Latest report 23 Mar 2026
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
- Individual concerns
- 24
- Date range
- 2015–2026
- Stated actions
- 30
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to restrict emergency cell bell silencing to staff
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Reissue local instructions requiring staff to physically check activated emergency cell bells and require supervisory oversight of timely responses.
Stated by HM Prison and Probation Service -
Action
Use a quality assurance process to identify weaknesses in emergency cell-bell responses and escalate performance issues through performance management.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to sound emergency alarms promptly
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of reliable alarm systems activatable from the water
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Revise and update the Code of Practice using information about the drowning, including consideration of water-level devices and alarm methods.
Stated by The Yacht Harbour Association (TYHA
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Concerns raised1
Failure of emergency cell bells to remain operable and alert prison staff
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Separate vulnerable and non-vulnerable prisoners across two induction wings.
Stated by HM Prison and Probation Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Separating vulnerable and non-vulnerable prisoners means the risks associated with their co-location, including bell cancellation, are no longer present.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to activate the emergency alarm system to summon the rapid response team promptly
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure of warning alarms to support immediate response throughout the care home
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Use walkie-talkies to coordinate night staff movements and communication throughout the building.
Stated by Broadland View Care Home -
Action
Install and operate a monitoring system linking room-entry records, sensor mats, audible alarms and response-time reporting.
Stated by Broadland View Care Home -
Action
Add sounders near Rooms 1 and 2 and test alarms to ensure emergency signals can be heard across the home.
Stated by Broadland View Care Home
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Concerns raised1
Failure to activate the ward emergency bell
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Conduct monthly resuscitation drills covering emergency alarms, equipment, oxygen, defibrillation, clinical handover and cardiac-checklist use.
Stated by North East London NHS Foundation Trust -
Action
Remind staff through daily roll call to sound the ERT alarm for all ward emergencies and ensure a timely ERT response.
Stated by North East London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to activate emergency alarms immediately
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Deliver drop-in refresher life-support training for clinical and administrative staff, emphasizing immediate help-seeking and pinpoint-alarm use.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Conduct a medical-emergency simulation with Derwent Centre staff and share incident learning for incorporation into current training.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Delays in calling 999 while seeking confirmation of smoke alarm activation
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Issue guidance to certified monitoring organisations requiring immediate fire-service contact when background alarms cannot be clearly identified as non-fire alarms.
Stated by TEC Services Association C.I.C. -
Action
Commence development of a Fire Call Handling Pathway Decision Support Tool after completing the Ambulance tool, with NFCC and LFB support if available.
Stated by TEC Services Association C.I.C.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Telecare and fire-service matters fall outside regulation, leaving no powers to prevent future deaths concerning those services.
Stated by Care Quality Commission
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Position
The investigation found no evidence that involved TEC services were specifically at fault, while identifying disjointed agency working as significant.
Stated by TEC Services Association C.I.C. -
Position
A Fire Call Handling Pathway Decision Support Tool is unlikely to be available until 2024 because development, testing, training and evaluation are required.
Stated by TEC Services Association C.I.C.
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Concerns raised1
Emergency cord requests failing to reach all nearby staff
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026