23 Mar 2026 Thomas Daniel RUGGIERO · Prevention of Future Deaths report Kent and Medway
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Concerns raised 1
Failure to restrict emergency cell bell silencing to staff View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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
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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
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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
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26 May 2025 Sarah Kathleen Hill · Prevention of Future Deaths report Cumbria
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Concerns raised 1
Failure to ensure call bells are within patients' reach View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Sarah Kathleen Hill · 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
Sarah Kathleen Hill was admitted for an elective ERCP to remove gallstones and developed worsening pancreatitis, perforation, multi-organ failure and cardiac arrest before dying in the early hours of 8 November 2024. Concerns included inadequate falls-risk assessment and reporting, insufficient documentation and monitoring, poor observability in a side room, and understaffing despite escalation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure call bells are within patients' reach
Wider context from the report “(2) There was a lack of documentation about the use of cot sides and the placement of the call bell within Mrs Hill's reach .
” Source location Sarah Kathleen Hill · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore mandatory electronic fields for bed-rail status and call-bell placement, including with the replacement-record supplier.
Verbatim wording from the response “Electronic Documentation Enhancement: The Web V electronic record system is under review to explore the options to introduce mandatory (cannot be bypassed) fields for bed rails status and call bell placement. NB: WebV will be replaced as part of the implementation of a new electronic patient record in 2026 and this feature will be explored with the supplier to ensure any progress made with WebV is not lost.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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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 the Nurse-in-Charge checklist to include bed rails, call bells and environmental safety.
Verbatim wording from the response “Daily Spot Checks: The daily Nurse-in-Charge quality checklist will be revised to include specific items on bed rails, call bells and environmental safety.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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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 FRAMP falls assessments were completed and updated appropriately; the identified failure concerned documenting and applying mitigating controls.
Verbatim wording from the response “Concern 1: Inadequate Falls Risk Assessment and Incident Reporting
Response:
The Trust acknowledges the failure to evidence appropriate falls risk assessment and timely incident reporting in Mrs Hill’s care.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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26 Nov 2024 Susan Paley · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to ensure that people with limited mobility have an easily reachable call bell when left in bed View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Harbour Healthcare Ltd.
Review and update residents’ call-bell risk assessments on admission, monthly, and after significant changes.
View source
Harbour Healthcare Ltd.
Translate call-bell and specific-aid requirements into care plans and time-specific handheld-device care actions reminding staff to provide and check them.
View source
Harbour Healthcare Ltd.
Upgrade the call-bell system to support advanced infrared assistive technology.
View source
Harbour Healthcare Ltd.
Reinforce call-bell and specific-aid procedures through documented staff supervisions and meetings.
View source See 1 more action
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Susan Paley · 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
Susan Paley, a resident of Hilltop Court Nursing Home with complex neurological problems and very limited mobility, died after choking on food while eating in bed on 11 May 2024. Concerns included that she had been left without an easily reachable call bell and that care staff did not use a checklist to confirm residents had required aids in place.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure that people with limited mobility have an easily reachable call bell when left in bed
Wider context from the report “1. Given Ms Paley’s significant health problems and very limited mobility, it is a matter of concern that she had been left in bed without a call bell to hand which she could easily reach should she need to summon assistance ; and
” Source location Susan Paley · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update residents’ call-bell risk assessments on admission, monthly, and after significant changes.
Verbatim wording from the response “a All residents have a call bell risk assessment in place. This is completed on admission and reviewed monthly thereafter or in response to significant changes in the resident’s condition. This was reviewed and updated in June 2024.” Source location Response from Harbour Healthcare
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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 Translate call-bell and specific-aid requirements into care plans and time-specific handheld-device care actions reminding staff to provide and check them.
Verbatim wording from the response “b The outcome of the call bell risk assessment is then communicated into a care plan which details specific measures to ensure call bell devices, where in use, are working and within reach.” Source location Response from Harbour Healthcare
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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 Upgrade the call-bell system to support advanced infrared assistive technology.
Verbatim wording from the response “f Harbour Healthcare have currently upgraded the existing call bell system to enable the use of more advanced, infra-red assistive technology. This work has now been completed.” Source location Response from Harbour Healthcare
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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 Reinforce call-bell and specific-aid procedures through documented staff supervisions and meetings.
Verbatim wording from the response “e The above measures are being regularly reinforced during documented supervisions and staff meetings.” Source location Response from Harbour Healthcare
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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 call-bell assessments, care plans and planned actions are considered sufficient to ensure devices are functioning and within reach.
Verbatim wording from the response “a All residents have a call bell risk assessment in place. This is completed on admission and reviewed monthly thereafter or in response to significant changes in the resident’s condition. This was reviewed and updated in June 2024.” Source location Response from Harbour Healthcare
Open published response
26 Nov 2024 Elan Gransford Adams · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to provide a reliable resident call bell system that staff can hear and respond to View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Abbey Healthcare
Disseminate the Coroner’s concerns and updated Emergency Protocol to all services, and require managers to check emergency equipment and communication systems.
View source
Abbey Healthcare
Upgrade the entire Manor Farm nurse call system.
View source
Abbey Healthcare
Use updated manager walk-round checks, half-hourly resident checks, and ad-hoc call-bell tests to verify call-bell availability and operation.
View source
Abbey Healthcare
Apply the updated Call Bell Policy, including urgent reporting, repair or replacement, risk assessment, and Regional Director approval when failures cannot be immediately repaired.
View source
Abbey Healthcare
Train all new staff during induction on the updated Call Bell Policy and monitor compliance.
View source See 2 more actions
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Elan Gransford Adams · 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
Elan Gransford Adams, a nursing home resident, choked on a burger on 5 February 2024 and died at hospital later that evening. The substantive concerns included poor-quality emergency-call communication, unclear clinical information provided to the ambulance controller, and a faulty resident call bell with limited assurance that staff could hear it during busy periods.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide a reliable resident call bell system that staff can hear and respond to
Wider context from the report “(3) The resident call bell had been faulty for an extended period of time . Whilst a handheld bell was provided, there was little assurance that staff could hear this during busy periods , such as during mealtimes. The family had been present on a prior occasion when the temporary bell had been rung and no staff attended .
” Source location Elan Gransford Adams · Prevention of Future Deaths report
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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 Disseminate the Coroner’s concerns and updated Emergency Protocol to all services, and require managers to check emergency equipment and communication systems.
Verbatim wording from the response “To ensure that as a company, we have implemented change across all our sites, on 5 December 2024 we contacted each service to make them aware of the Coroner’s concerns following the Inquest in this matter. A copy of the Coroner’s Regulation 28 was provided to all managers. The Emergency Protocol, which was updated in November 2024, was circulated simultaneously. We asked all Home Managers to check the following in their service:” Source location Response from Abbey Healthcare
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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 Upgrade the entire Manor Farm nurse call system.
Verbatim wording from the response “Following the Inquest and a request for feedback from all services within Abbey Healthcare, intermittent faults were identified with the call bell systems at Manor Farm. This was in keeping with our immediate checks following the Inquest. There were no call bell issues identified elsewhere.” Source location Response from Abbey Healthcare
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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 updated manager walk-round checks, half-hourly resident checks, and ad-hoc call-bell tests to verify call-bell availability and operation.
Verbatim wording from the response “Our Manager Daily Walk Round Checklist has been updated (Appendix 5). Where spot checks of residents rooms are completed, it is now part of the check to ascertain if ‘all calls are within reach and operational’. This includes a:” Source location Response from Abbey Healthcare
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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 Apply the updated Call Bell Policy, including urgent reporting, repair or replacement, risk assessment, and Regional Director approval when failures cannot be immediately repaired.
Verbatim wording from the response “Half hourly checks are also conducted on residents, and ad-hoc tests of their call bells are undertaken. Where call bell failures are identified, staff are expected to follow the procedure as set out in our updated Call Bell Policy (Appendix 6). The policy, updated in November 2024, makes clear that in the event of a call bell failure, the following steps should be taken:” Source location Response from Abbey Healthcare
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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 Train all new staff during induction on the updated Call Bell Policy and monitor compliance.
Verbatim wording from the response “All staff, as part of their induction, will receive training on this policy. Compliance with this policy will be monitored and any non-compliance may result in disciplinary action.” Source location Response from Abbey Healthcare
Open published response
25 Oct 2024 Sylvia Prichard · Prevention of Future Deaths report Surrey
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Concerns raised 2
Failure of oversight and auditing to identify non-implementation of the call bell response time policy View source Delays in responding to call bells View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Avery Healthcare Group
Implement daily call-bell response reporting and management oversight, with delayed responses investigated and staff performance addressed.
View source
Avery Healthcare Group
Introduce an internal audit framework covering call-bell response times and falls-minimisation plans, with results shared with staff.
View source
Avery Healthcare Group
Conduct Quality Team compliance inspections to oversee audit findings and ensure actions are completed promptly.
View source
Avery Healthcare Group
Review peak-hour staffing and optimise staff allocation to improve call-bell response efficiency.
View source
Avery Healthcare Group
Relaunch the updated call-bell policy and communicate the required two-to-five-minute response time to staff.
View source
Avery Healthcare Group
Review call-bell technology, provide appropriate equipment access, and deploy care managers during busy periods to reduce response times.
View source
Avery Healthcare Group
Issue a significant-learning briefing on call-bell response times and policy adherence.
View source
Avery Healthcare Group
Reconfigure the call-bell system to escalate unanswered calls after three minutes to an emergency tone.
View source
Avery Healthcare Group
Embed revised call-bell procedures in staff briefings and induction training.
View source See 6 more actions
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AI-generated summary
Sylvia Prichard · 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
Sylvia Prichard, a resident of Moorlands Lodge Care Home, had an unwitnessed fall on 28 March 2024 after a delayed response to her call bell and later died in hospital from a traumatic acute subdural haemorrhage. The concerns included the absence of a falls minimisation plan, outdated and conflicting care-plan information, persistent delays in responding to call bells, and inadequate oversight and auditing of these issues.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of oversight and auditing to identify non-implementation of the call bell response time policy
Wider context from the report “- The Coroner is concerned that Avery Healthcare’s oversight and auditing measures failed to identify that the call bell response time policy was not being implemented at Moorlands Lodge Care Home for many months and further failed to identify that falls minimisation plans were not being completed for residents.
” Source location Sylvia Prichard · Prevention of Future Deaths report
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 Delays in responding to call bells
Wider context from the report “- Audits show that, despite efforts to improve call bell response times, a significant number of call bells are still not responded to within two to five minutes . This is of concern as residents who are unable to move due to a medical emergency or fall are not able to use the emergency buttons on the wall.
” Source location Sylvia Prichard · Prevention of Future Deaths report
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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 Implement daily call-bell response reporting and management oversight, with delayed responses investigated and staff performance addressed.
Verbatim wording from the response “• Managers now receive daily log reports on call bell response times, allowing immediate intervention for delays and further investigation for non-compliance. The call bell logs are reviewed by the Home Manager on a daily basis and shared with the senior Operations Team for further oversight.” Source location Response from Avery Healthcare Group
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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 Introduce an internal audit framework covering call-bell response times and falls-minimisation plans, with results shared with staff.
Verbatim wording from the response “• A new internal audit framework has been introduced, focusing on critical areas such as call bell response times and falls minimisation plans. All audit results will be shared transparently with staff to foster accountability.” Source location Response from Avery Healthcare Group
Open published response
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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 Quality Team compliance inspections to oversee audit findings and ensure actions are completed promptly.
Verbatim wording from the response “• Internal Compliance Inspections are conducted by the Quality Team, which oversee all audit findings and ensure that actions are completed promptly and consider whether they may prompt an inspection on emerging risks.” Source location Response from Avery Healthcare Group
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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 peak-hour staffing and optimise staff allocation to improve call-bell response efficiency.
Verbatim wording from the response “• Staffing levels during peak hours have been reviewed to ensure they align with residents’ care needs.” Source location Response from Avery Healthcare Group
Open published response
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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 Relaunch the updated call-bell policy and communicate the required two-to-five-minute response time to staff.
Verbatim wording from the response “• The updated call bell response policy has been relaunched, and all staff are now fully aware of the expected 2–5-minute response time.” Source location Response from Avery Healthcare Group
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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 call-bell technology, provide appropriate equipment access, and deploy care managers during busy periods to reduce response times.
Verbatim wording from the response “• A technology review within the Home has been undertaken to ensure all staff have access to the correct equipment ensuring they are all notified of calls. During the busy times of the day care managers support the team on the floor to ensure minimisation of response times.” Source location Response from Avery Healthcare Group
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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 significant-learning briefing on call-bell response times and policy adherence.
Verbatim wording from the response “• In May, the Home issued a Significant Learning briefing regarding call bell response times and adherence to the policy.” Source location Response from Avery Healthcare Group
Open published response
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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 Reconfigure the call-bell system to escalate unanswered calls after three minutes to an emergency tone.
Verbatim wording from the response “• Furthermore, there has now been a full review and reconfiguration of the call bell system. This work will ensure that any call bell activated from any source, i.e. pendant or call point will ring for 3 minutes on the ordinary tone. If the call bell is not answered within 3 minutes, the call bell will be automatically escalated and change to an emergency call bell which has a different tone. The team are aware that emergency bells must be answered immediately, and this response is a whole home approach. This new system has made the use of the wrist-worn emergency watches unnecessary.” Source location Response from Avery Healthcare Group
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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 Embed revised call-bell procedures in staff briefings and induction training.
Verbatim wording from the response “• Staff have been fully briefed in the change in policy and the changes have been embedded into the induction training on the use of call bells.” Source location Response from Avery Healthcare Group
Open published response
9 Sep 2024 Ian William Deavall · Prevention of Future Deaths report Greater Manchester West
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Concerns raised 1
Failure of emergency cell bells to remain operable and alert prison staff View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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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.
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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
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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
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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
Open published response
19 Jul 2024 Rita Howells · Prevention of Future Deaths report Herefordshire
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Concerns raised 1
Unsatisfactory procedures for establishing whether call bells are working View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Wye Valley NHS Trust
Implement a standardised process and frequency for checking inpatient call bells and reporting faults.
View source
Wye Valley NHS Trust
Add digital call-bell check prompts and establish weekly housekeeper call-bell checks.
View source
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AI-generated summary
Rita Howells · 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
Rita Howells was transferred to Bromyard Hospital for rehabilitation and discharge planning, later became confused and agitated, fell from her bed, and was found to have an intracerebral haemorrhage. The concerns identified were that bed rails were routinely erected before a falls assessment, contrary to policy, and that procedures for establishing whether a call bell was working were unsatisfactory.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unsatisfactory procedures for establishing whether call bells are working
Wider context from the report “(2) The procedures to establish whether a call bell is working are unsatisfactory
” Source location Rita Howells · Prevention of Future Deaths report
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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 Implement a standardised process and frequency for checking inpatient call bells and reporting faults.
Verbatim wording from the response “Ward areas perform checks of the call bell system and report issues directly to Sodexo, who undertake any remedial works. Upon review, the checks vary in frequency across different wards and are not subject to a standardised checking process. A standard approach will be implemented in response to this regulation 28.” Source location Response from Wye Valley NHS Trust
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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 digital call-bell check prompts and establish weekly housekeeper call-bell checks.
Verbatim wording from the response “As part of the improvements to our digital nurse noting, a review of all assessments (questions, layout, and functionality) has been ongoing for a number of months. A number of changes are being implemented to improve the risk assessments associated with falls, bedrails and level of observation. This will simplify and combine these assessments to ensure completion at the same time. Given the inconsistency with call bell checks a prompt for a check of the call bell has been added to the digital system and additionally as a safety net, the housekeeper will perform a weekly check.” Source location Response from Wye Valley NHS Trust
Open published response
26 Jan 2024 Jeanine Maria HUGGINS · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to assess patients’ ability to use a call bell and provide suitable alternatives when they cannot View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Jeanine Maria HUGGINS · 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
Jeanine Maria Huggins, who was being treated for diffuse large B-cell lymphoma, was admitted with neutropenic sepsis, dehydration and acute kidney injury and initially showed clinical improvement. She was found not breathing during the night of 9 May 2022 and could not be resuscitated; the inquest concluded that she died from natural causes, with coronary artery atheroma and lymphoma on treatment recorded as the medical cause of death. Concerns included the absence of a formal risk assessment for patients placed in side rooms, including assessment of their ability to use a call bell or suitable alternatives, and failures to escalate raised NEWS scores in accordance with guidance.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to assess patients’ ability to use a call bell and provide suitable alternatives when they cannot
Wider context from the report “2. There is no formal requirement to ensure that a patient is risk assessed with regard to ability to use a call bell and, if they are unable, to consider suitable alternatives , especially when in a side room and there is no other way to attract staff attention .
” Source location Jeanine Maria HUGGINS · Prevention of Future Deaths report
Open source report
Concerns raised 1
Emergency cord requests failing to reach all nearby staff View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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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.
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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
Open source report
22 Jun 2022 Derek Holmes · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Inadequate processes to ensure patient call-bells are working at all times View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Derek Holmes · 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 Holmes, who had advanced metastatic prostate cancer and congestive cardiac failure, was admitted to hospital with several acute problems and fell while attempting to get out of bed. He sustained a left hip fracture requiring surgery and died after developing vomiting and signs of a chest infection. Concerns included errors in the Trust’s Root Cause Analysis, inadequate formal examination of issues including patient call-bells and delays in obtaining specialist advice, and the grading of the fall’s harm.
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 Inadequate processes to ensure patient call-bells are working at all times
Wider context from the report “1. Notwithstanding the fact that the document had passed through the Trust’s quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr Holmes’s fall contained a number of basic and obvious errors. Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths;
2. The formal learning derived from the Trust’s investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as:
• the adequacy of existing processes designed to ensure patient call-bells are working at all times ; and
• why a delay has occurred in obtaining advice from a specialist hospital in the present case and whether the processes by which such advice is obtained are fit for purpose.
3. Connected with the above, the Trust does not appear to have revisited the grading of “moderate” harm originally assigned to Mr Holmes’s fall on the Acute Medical Unit notwithstanding his death being reported to the Coroner on the basis there was reason to suspect it contributed to his death. The court heard evidence to the effect that this grading informs the nature and extent of investigation which arises from a patient safety incident (thus impacting upon the learning which can be derived from such an incident).
” Source location Derek Holmes · Prevention of Future Deaths report
Open source report
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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 Implement revised call-bell, oxygen and suction checking through a safety checklist, standard operating procedure and auditable oversight.
Verbatim wording from the response “In relation to the issue raised relating to patient call bells, a safety checklist has been revised with an accompanying standard operating procedure intended to support the regular testing and checks of emergency equipment within all inpatient areas. This includes a daily check by operational staff of the call bell, oxygen and suction located at each bedside. This is overseen by a weekly assessment, recorded within the safety checklist. This is then auditable as part of assessments completed by members of the Safer Care Team for each area and reviewed as part of the Ward accreditation process. As this is a new process, this has been socialised with the divisional leadership teams to ensure their views and comments are considered in the implementation of this.” Source location Response from NHS Tameside and Glossop Integrated Care
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.