Recurring concern

Failure of emergency alarm response

First to latest report 16 Sep 2015 — 23 Mar 2026

Reports that mention this concern
22
Times this concern has been raised
24
Stated actions linked to this concern
30

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.

What is 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 and published responses 22 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Kent and Medway

    AI-generated summary

    Thomas Daniel RUGGIERO · 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

    Thomas Daniel Ruggiero, a 39-year-old prisoner at HMP Swaleside, was found unresponsive in his cell on 16 November 2024 after ligaturing himself and died later that day. The report identifies concerns about the emergency cell bell system, incomplete ACCT documentation, confusion over calling a “code blue”, and staffing, experience and communication at the prison, with risks to future prisoners remaining.

    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 restrict emergency cell bell silencing to staff

    Wider context from the report

    “(1) Emergency Cell Bell System During the evidence there was CCTV footage of other prisoners silencing Mr Ruggiero's cell bell from outside his cell door. The jury found that this hampered the ability of prison staff to respond and react to Mr Ruggiero's needs and distress in the hour or so before his being found unresponsive in his cell. I was told in evidence that anyone (other prisoners or staff members) can silence an emergency call bell at the push of a button outside the relevant cell door and there is no mechanism or system in place to ensure that the cell bell can only be silenced by staff. The evidence was that as and when a cell bell is silenced, staff assume that the call for assistance has been answered. There was clear evidence that this situation has not changed in any way since November 2024. As a result the emergency cell bell system remains highly vulnerable to both misuse and abuse. In my opinion, this raises a significant risk of future deaths if action is not taken. ”

    Source location

    Thomas Daniel RUGGIERO · 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

    Reissue local instructions requiring staff to physically check activated emergency cell bells and require supervisory oversight of timely responses.

    Verbatim wording from the response

    “Your first concern relates to the emergency cell bell system at HMP Swaleside. I have received assurance from the Governor that following this inquest local instructions were reissued to all operational staff, clearly setting out the expectation that staff must physically check every emergency cell bell that has been activated. Supervising Officers are required to oversee and monitor responses to cell bells, and directly challenge officers where responses to cell bells are not completed in a timely way.”

    Source location

    Response from HM Prison & Probation Service
    Page 1 · response
    Published 26 March 2026

    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

    Use a quality assurance process to identify weaknesses in emergency cell-bell responses and escalate performance issues through performance management.

    Verbatim wording from the response

    “A quality assurance process has been introduced to identify areas of weakness around responding to cell bells, and where any performance related issues are identified these will be escalated through the performance management process.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 26 March 2026

    Open published response

  2. East London

    AI-generated summary

    Madeline Reding · 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

    Madeline Reding, a 79-year-old nursing-home resident with advanced vascular dementia, became unwell after lunch on 17 May 2024, regurgitated food, developed an upper-airway obstruction and respiratory arrest, and died that afternoon. The inquest identified delayed and disorganised staff responses, including a failure to sound the emergency alarm or make an immediate 999 call, delayed CPR, and ineffective first aid.

    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 sound emergency alarms promptly

    Wider context from the report

    “2. An emergency alarm was not sounded promptly. ”

    Source location

    Madeline Reding · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Oxfordshire

    AI-generated summary

    Catherine Sarah Forbes · 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 Forbes, aged 57, drowned after falling unwitnessed into the Thames and Kennet Marina late on 31 March 2023; she was unable to climb out using a nearby ladder. The principal concerns relate to the design, length, grip, number, placement and visibility of marina ladders, and to the availability of flotation devices, platforms and alarm systems to help people who fall into the water escape or raise the alarm.

    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 reliable alarm systems activatable from the water

    Wider context from the report

    “I am mindful that safety improvements have been made at the Thames and Kennet Marina, specifically in relation to risk assessment and ladders having been upgraded to 2m in length with a minimum of 1m beneath the water. This is welcomed, not least because Catherine Forbes was the third person to drown in similar circumstances at the marina since 2016. I have continuing industry wide concerns which, I believe, your organisation is in a position to take account of and review. I note from your response dated 28 May 2024 that British Marine and YHA are keen to ensure that marinas are as safe as possible. The particular concern is in relation to persons falling into the marina, on their own and unwitnessed, and what measures are in place to enable them to get out or raise the alarm. Perhaps the main issue relates to sufficiently designed ladders, in terms of length and grip, but also their number, placement and visibility from the water at day or night (flags, fluorescent signage, lighting for example). It is not for me to make recommendations and I am not an expert of course on marina safety but it is my duty to raise concerns that reflect the evidence heard at inquest and the issues helpfully raised by Ms Forbes family. With this in mind, I enquire if there are flotation devices or small platforms which sit on the surface of the water which a person could access more easily? I also enquire if there are alarm systems that exist or could be considered which can be activated from the water. I appreciate of course they would need to be non-electrical or non-battery or fully waterproof. Further, with regard to the Gold Anchor Award, it appears that the important issue of safety is not one of the key attributes or evaluation categories. Thames and Kennet held the top 5 Gold Anchors at the time of Ms Forbes death but were not fully compliant with the TYHA 2013 Code of Practice in relation to the length of all ladders. I note the 2013 Code is being reviewed from June 2024 and I enquire if the concerns raised in this report can be taken into account, in conjunction with designers and suppliers who the TYHA consult with. I can advise that I will be supplying a copy of this report to the HSE and also the organisation with oversight of District Council’s who often have responsibility for health and safety enforcement of marinas instead of the HSE. ”

    Source location

    Catherine Sarah Forbes · 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

    Revise and update the Code of Practice using information about the drowning, including consideration of water-level devices and alarm methods.

    Verbatim wording from the response

    “Through these objectives and the following actions, TYHA aims to further enhance water safety standards across marinas and reduce the likelihood of similar tragedies in the future. The Code of Practice revision will consider the viability of water level devices to assist with self-rescue and methods of raising the alarm from the water.”

    Source location

    The Yacht Harbour Association
    Page 1 · response
    Published 19 November 2024

    Open published response

  4. Greater Manchester West

    AI-generated summary

    Ian William Deavall · 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

    Ian William Deavall, who had ischaemic heart disease and hypotension, suffered a cardiac arrest in his cell at HMP Forest Bank on 24 January 2023. The emergency cell bell was deactivated by another prisoner, cancelling the alert in the wing office and removing the only indication of the exact cell, so staff became aware of the emergency more by accident than design. The report identifies an ongoing risk because emergency cell bells can still be readily deactivated by other prisoners and no fail-safe measures are currently proposed.

    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 emergency cell bells to remain operable and alert prison staff

    Wider context from the report

    “(1) The response to a medical emergency will generally be time critical. (2) The risk that non-VP prisoners will victimise VP prisoners is a recognised one. (3) That prison staff became aware of the medical emergency in the Deceased’s case was more by accident than design (depending as it did on the caprice of Prisoner A). There remains a risk that future deaths could occur as it remains the case that emergency cell bells at HMP Forest Bank can be deactivated readily and altogether by other prisoners and no action to implement fail-safe measures is currently proposed. ”

    Source location

    Ian William Deavall · 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

    Separate vulnerable and non-vulnerable prisoners across two induction wings.

    Verbatim wording from the response

    “HMP Forest Bank has advised that the induction is now split across two wings, which allows VPs and non-VPs to be housed separately, which means that the risks to VPs associated with co-location, including the cancelling of cell call bells by non-VPs, are no longer present.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 10 September 2024

    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

    Separating vulnerable and non-vulnerable prisoners means the risks associated with their co-location, including bell cancellation, are no longer present.

    Verbatim wording from the response

    “HMP Forest Bank has advised that the induction is now split across two wings, which allows VPs and non-VPs to be housed separately, which means that the risks to VPs associated with co-location, including the cancelling of cell call bells by non-VPs, are no longer present.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 10 September 2024

    Open published response

  5. Inner North London

    AI-generated summary

    Nimo OSMAN · 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

    Nimo Osman was in state detention under a Hospital Order and receiving psychiatric inpatient care when she collapsed on the ward on 21 April 2022. She was unresponsive for over half an hour before an ambulance was called and died in hospital on 23 April 2022 from hypoxic ischaemic brain injury. The principal concerns were delays in recognising the emergency and calling an ambulance, whether learning had been embedded among staff, completion of venous thromboembolism assessments, and ambiguity in the Trust’s venous thromboembolism policy.

    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 activate the emergency alarm system to summon the rapid response team promptly

    Wider context from the report

    “Following the discovery of Ms Osman’s collapse on Rosebank Ward on 21 April 2022, it took staff a significant number of minutes to recognise that instead of just lying on the floor, Ms Osman was actually unrousable. A few minutes later a nurse arrived on the scene, who decided to summon the duty senior nurse (DSN) by radio, rather than activating the alarm system, which would have summoned the rapid response team sooner. The DSN contacted the duty doctor to inform them that there was a medical emergency, prior to calling an ambulance. In total, Ms Osman had been on the floor and unresponsive for over half an hour before an ambulance was called. I also viewed the CCTV evidence covering this course of events. I heard evidence from a consultant neurosurgeon and a consultant neuroradiologist. Their evidence was such that, in Ms Osman’s case this delay would not have made a difference because she had suffered a catastrophic brain injury and her condition was likely to have been unsalvageable from the moment she was found unresponsive on the floor. However, I consider that a delay of circa 30 minutes in calling an emergency ambulance raises a considerable risk, if repeated in the case of another patient requiring emergency treatment at hospital. I was initially reassured by the evidence of a very senior member of nursing staff (Nurse A) about the work that has been done to educate all staff that anyone can call 999 for an ambulance if they consider it necessary, without seeking the advice of colleagues or the specific approval of a doctor. I was told by Nurse A that they were confident that the education and training undertaken with staff had had a positive impact and that a delay of this kind was unlikely to be repeated in the future. However, a senior nurse (Nurse B) who was on duty at the time of Ms Osman’s collapse told me in their evidence (over two years after Ms Osman’s death) that nursing staff cannot and would not call an ambulance of their own volition. Nurse B told me that she would only ever call an ambulance if told to do so by a more senior clinician. Nurse B went on to tell me that it was often the case that by the time an ambulance had been called and arrived, a patient would die; the manner in which this evidence was given led me to form the view that the Nurse B seemed to think that this was ‘just one of those things that happens’. While I was told by Nurse A (who seemed genuinely concerned) that this matter would be escalated and addressed, I was concerned that over two years since Ms Osman’s death this view was still held by a senior and experienced member of the nursing team who led a team of more junior nurses. My concern was such that I am not reassured that sufficient steps have been taken to prevent the recurrence of such a risk in the future. ”

    Source location

    Nimo OSMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Norfolk

    AI-generated summary

    Eileen Marguerite WALSH · 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

    Eileen Marguerite WALSH, who had dementia and general frailty, fell unwitnessed at Broadland View Care Home, sustained a fractured neck of femur, and died on 3 March 2020. The inquest found that required hourly checks were not completed, her bed was not lowered, and the PIR sensor and pressure mat alarms did not sound; her death was contributed to by neglect. Concerns included incomplete night-working and monitoring arrangements, unreliable or editable care records, unclear policies on sleeping during night shifts, alarms that could not be heard everywhere, and failures to identify and learn from care and safeguarding concerns.

    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 warning alarms to support immediate response throughout the care home

    Wider context from the report

    “6. The warning alarms requiring immediate response cannot be heard in all places at the Care Home. It is understood walkie-talkies have been introduced for use by all staff but this adds in another step to be taken by staff before the alarm is responded to. ”

    Source location

    Eileen Marguerite WALSH · 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

    Use walkie-talkies to coordinate night staff movements and communication throughout the building.

    Verbatim wording from the response

    “- Daily notes audit: to monitor and audit night observations - Walkie Talkies: to enhance communication between staff and work in every area of the building Further actions taken: - additions made to ensure that staff limit the time in laundry/medication room - Daily audit of handover, this includes call mats. - 2nd line sampling of daily notes audit by the Care Manager - If there is a discrepancy in the night checks, staff are required to explain why and complete an incident form around this. - Interim monitor system put into Laundry and Meds room so that alarms can be heard. - Alarms tested to ensure that they can be heard from all rooms.”

    Source location

    Response from Broadland View Care Home
    Page 2 · response
    Published 4 August 2023

    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 and operate a monitoring system linking room-entry records, sensor mats, audible alarms and response-time reporting.

    Verbatim wording from the response

    “V. New monitoring system: This is part of our continuous improvement plans. The Medication system means that accurate recording of room checks, and response times will all be documented, and a detailed report can be obtained. There are sounders in all locations within the home ensuring that all staff can always hear the emergency alarms during their shift.”

    Source location

    Response from Broadland View Care Home
    Page 2 · response
    Published 4 August 2023

    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

    Add sounders near Rooms 1 and 2 and test alarms to ensure emergency signals can be heard across the home.

    Verbatim wording from the response

    “XII. The new alarm system has been installed, and the Night Working Policy has been updated to include this.”

    Source location

    Response from Broadland View Care Home
    Page 1 · response
    Published 4 August 2023

    Open published response

  7. East London

    AI-generated summary

    Winbourne Gregory Charles · 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

    Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance processes.

    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 activate the ward emergency bell

    Wider context from the report

    “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include; a. A ward emergency bell was not sounded, b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles. c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination, d. Duty doctors were not called promptly, e. Oxygen administration was delayed, f. An on-site defibrillator was not used by staff g. Staff could or would not provide a clear and relevant history to paramedics. ”

    Source location

    Winbourne Gregory Charles · 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

    Conduct monthly resuscitation drills covering emergency alarms, equipment, oxygen, defibrillation, clinical handover and cardiac-checklist use.

    Verbatim wording from the response

    “4. Risk management (shortcomings in responding to the emergency) – the Coroner found that the Trust did not respond to the | 5. | Resus drills which include all of these elements are taking place monthly. | 1. Resus drills to take place monthly”

    Source location

    NELFT NHS Foundation Trust Action Plan
    Page 4 · response
    Published 5 May 2023

    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

    Remind staff through daily roll call to sound the ERT alarm for all ward emergencies and ensure a timely ERT response.

    Verbatim wording from the response

    “6. The ERT alarm should be sounded in all ward emergency situations and the ERT team will respond”

    Source location

    NELFT NHS Foundation Trust Action Plan
    Page 5 · response
    Published 5 May 2023

    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

    Concerns about care provision and coordination are mainly for the NHS Trust to address.

    Verbatim wording from the response

    “Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 5 May 2023

    Open published response

  8. Essex

    AI-generated summary

    Sharon Elizabeth Langley · 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

    Sharon Elizabeth Langley, an inpatient with Severe Depressive Disorder and Psychosis, died by immersion in water while unsupervised in an assisted bathroom at Princess Alexandra Hospital on 10 August 2019. The principal concerns included failures in the immediate emergency response, inadequate communication and coordination, shortcomings in bathroom and high-risk-area safety measures, confusion about bath-plug controls, unreliable investigation and learning processes, and inadequate record keeping and risk documentation.

    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 activate emergency alarms immediately

    Wider context from the report

    “(1) Essex Partnership NHS Foundation Trust staff immediate emergency response was not followed: a. pinpoint alarms were not activated immediately on finding Sharon Langley unresponsive b. there was a delay calling the ambulance and basic key information about the type of the emergency was not relayed: i. by qualified nurses who made the 999 calls, or ii. to paramedics on attendance c. there was a delay informing the site co-ordinator of the emergency even though she was based on the ward and there was a lack of co-ordination of the emergency resulting in the ambulance being called a second time by the site co-ordinator d. staff trained in basic life support did not assist the two nurses who were attempting to resuscitate Sharon Langley ”

    Source location

    Sharon Elizabeth Langley · 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

    Deliver drop-in refresher life-support training for clinical and administrative staff, emphasizing immediate help-seeking and pinpoint-alarm use.

    Verbatim wording from the response

    “- EPUT’s Head of Deteriorating Patient Pathways and Resuscitation Training Officer is working closely with mental health wards to facilitate drop-in ‘refresher’ life support training for clinical and administrative staff dealing with emergency situations. During”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 1 · response
    Published 7 March 2023

    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

    Conduct a medical-emergency simulation with Derwent Centre staff and share incident learning for incorporation into current training.

    Verbatim wording from the response

    “- The issue of calling for help as soon as possible is also shared during the weekly ‘virtual’ drop-in sessions which focus on the deteriorating patient. Head of Deteriorating Patient Pathways and Resuscitation Training Officer will continue to work with staff at the Derwent Centre to conduct a medical emergency simulation with the team and the importance of calling for help at the earliest possible opportunity is relayed during the post simulation feedback. In addition, the Trust’s training team have shared details of the learning from this incident and request for incorporation and sharing within the current training programme (1b, 1c).”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 7 March 2023

    Open published response

  9. Inner North London

    AI-generated summary

    Reginald Cauthery · 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

    Reginald Cauthery was a frail man with limited mobility who lived alone and died in hospital after sustaining extensive burns in a smouldering fire at his flat. The report raised concerns that his telecare service was not reviewed despite his increased fire risk and deteriorating mobility, and that his smoke alarms were not connected to the telecare system, delaying contact with the Fire Brigade.

    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 calling 999 while seeking confirmation of smoke alarm activation

    Wider context from the report

    “(3) If Mr Cauthery’s smoke alarm had been connected to his telecare system, the call would have been answered as a priority. In addition, the call handler would not have spent several minutes seeking confirmation that the smoke alarm was going off before making a 999 call. ”

    Source location

    Reginald Cauthery · Prevention of Future Deaths report
    Page 4 · 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 guidance to certified monitoring organisations requiring immediate fire-service contact when background alarms cannot be clearly identified as non-fire alarms.

    Verbatim wording from the response

    “As stated in the discussion with AM, they are amending their operational procedures should alarms be heard in the background of a call, but we will also be issuing guidance to the same effect for all our certified monitoring organisations. This guidance will be issued by the end of November this year.”

    Source location

    Response from TEC Services Association
    Page 6 · response
    Published 20 October 2022

    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

    Commence development of a Fire Call Handling Pathway Decision Support Tool after completing the Ambulance tool, with NFCC and LFB support if available.

    Verbatim wording from the response

    “Once our work on the Ambulance Pathway Decision Support Tool is complete, we will commence work on a similar tool for Fire Call Handling, with the support of NFCC and LFB if they are willing to do so. It must be recognised that it is likely that such a tool would not be available for use by service providers”

    Source location

    Response from TEC Services Association
    Page 6 · response
    Published 20 October 2022

    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

    Telecare and fire-service matters fall outside regulation, leaving no powers to prevent future deaths concerning those services.

    Verbatim wording from the response

    “However, the matters of concerns highlighted in the Regulation 28 report relate to services outside our scope of regulation. We do not regulate the fire service or the”

    Source location

    Response from Home Care Quality Commission
    Page 1 · response
    Published 20 October 2022

    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 investigation found no evidence that involved TEC services were specifically at fault, while identifying disjointed agency working as significant.

    Verbatim wording from the response

    “On this occasion and from our discussions, we could not see any evidence that the TEC services involved, were at fault in any specific way, but we do feel that the disjointed way of working between agencies is a significant factor in this case. However, we do believe that lessons can be learnt.”

    Source location

    Response from TEC Services Association
    Page 5 · response
    Published 20 October 2022

    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

    A Fire Call Handling Pathway Decision Support Tool is unlikely to be available until 2024 because development, testing, training and evaluation are required.

    Verbatim wording from the response

    “Once our work on the Ambulance Pathway Decision Support Tool is complete, we will commence work on a similar tool for Fire Call Handling, with the support of NFCC and LFB if they are willing to do so. It must be recognised that it is likely that such a tool would not be available for use by service providers”

    Source location

    Response from TEC Services Association
    Page 6 · response
    Published 20 October 2022

    Open published response

  10. South Yorkshire (Western)

    AI-generated summary

    Brian Parry · 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

    Brian Parry died at Brunswick Retirement Village on 3 November 2021 after choking on food. The report identified delays in calling emergency services, an emergency cord system that did not alert nearby staff, limited confidence in first-aid training, and no advanced first aider available on site.

    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

    Emergency cord requests failing to reach all nearby staff

    Wider context from the report

    “I am concerned that when the emergency cord was pulled, the request for assistance went to care staff who were between 1 and 4 minutes away from the restaurant rather than to all staff, some of whom were near by ”

    Source location

    Brian Parry · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026