First reported 6 Mar 2015•Latest report 23 Mar 2026
Definition
What this concern includes
Includes deficiencies in call bell or emergency cell bell systems and their dedicated controls where the failure could prevent a person from summoning assistance, obscure or misrepresent a call, or delay an appropriate response.
Not included
Excludes generic staffing, training, documentation, auditing or communication failures unless they are specifically tied to the operation or control of a call bell system.
Excludes ambulance, clinical observation and other emergency-response processes that do not concern a call bell system.
Excludes general environmental or care deficiencies unrelated to access to, operation of or response through a call bell system.
Reports
20
Distinct published reports
Individual concerns
24
A report can raise multiple concerns
Date range
2015–2026
First to latest report issue date
Stated actions
41
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
HM Prison and Probation Service2
Abbey Healthcare1
Avery Healthcare Group1
Brunswick Gardens Village1
Carillion (AMBS) Limited1
Crown Care Group1
Department of Health and Social Care1
FirstPort Retirement Property Services Limited1
Harbour Healthcare Ltd.1
Hereford County Hospital1
Hillbrook Grange1
Leicestershire Partnership NHS Trust1
Ministry of Justice1
Norfolk and Norwich University Hospital1
Norfolk and Norwich University Hospitals NHS Foundation Trust1
NHS trust5
Private limited company5
Healthcare site4
Prison or young offender institution4
Care-home operator2
Executive agency2
Ministerial department2
Multi-service care provider1
Residential care home1
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.
Kent and Medway
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 concerns
Each 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
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 ServiceStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
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 ServiceStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Cumbria
Concerns raised1
Failure to ensure call bells are within patients' reach
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Explore mandatory electronic fields for bed-rail status and call-bell placement, including with the replacement-record supplier.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 June 2025.
Action
Revise the Nurse-in-Charge checklist to include bed rails, call bells and environmental safety.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 June 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
FRAMP falls assessments were completed and updated appropriately; the identified failure concerned documenting and applying mitigating controls.
Stated by North Cumbria Integrated Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to ensure that people with limited mobility have an easily reachable call bell when left in bed
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 concerns
Each 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.4
Action
Review and update residents’ call-bell risk assessments on admission, monthly, and after significant changes.
Stated by Harbour Healthcare Ltd.Stated completedThe respondent said that this action was complete when they made their response on 28 November 2024.
Action
Translate call-bell and specific-aid requirements into care plans and time-specific handheld-device care actions reminding staff to provide and check them.
Stated by Harbour Healthcare Ltd.Stated completedThe respondent said that this action was complete when they made their response on 28 November 2024.
Action
Upgrade the call-bell system to support advanced infrared assistive technology.
Stated by Harbour Healthcare Ltd.Stated completedThe respondent said that this action was complete when they made their response on 28 November 2024.
Action
Reinforce call-bell and specific-aid procedures through documented staff supervisions and meetings.
Stated by Harbour Healthcare Ltd.Stated in progressThe respondent said that this action was in progress when they made their response on 28 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing call-bell assessments, care plans and planned actions are considered sufficient to ensure devices are functioning and within reach.
Stated by Harbour Healthcare Ltd.Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Failure to provide a reliable resident call bell system that staff can hear and respond to
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.5
Action
Disseminate the Coroner’s concerns and updated Emergency Protocol to all services, and require managers to check emergency equipment and communication systems.
Stated by Abbey HealthcareStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Action
Upgrade the entire Manor Farm nurse call system.
Stated by Abbey HealthcareStated in progressThe respondent said that this action was in progress when they made their response on 2 December 2024.
Action
Use updated manager walk-round checks, half-hourly resident checks, and ad-hoc call-bell tests to verify call-bell availability and operation.
Stated by Abbey HealthcareStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Action
Apply the updated Call Bell Policy, including urgent reporting, repair or replacement, risk assessment, and Regional Director approval when failures cannot be immediately repaired.
Stated by Abbey HealthcareStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Action
Train all new staff during induction on the updated Call Bell Policy and monitor compliance.
Stated by Abbey HealthcareStated plannedThe respondent said that this action was planned when they made their response on 2 December 2024.
Surrey
Concerns raised2
Failure of oversight and auditing to identify non-implementation of the call bell response time policy
Delays in responding to call bells
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 concerns
Each 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.9
Action
Implement daily call-bell response reporting and management oversight, with delayed responses investigated and staff performance addressed.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Introduce an internal audit framework covering call-bell response times and falls-minimisation plans, with results shared with staff.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Conduct Quality Team compliance inspections to oversee audit findings and ensure actions are completed promptly.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Review peak-hour staffing and optimise staff allocation to improve call-bell response efficiency.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Relaunch the updated call-bell policy and communicate the required two-to-five-minute response time to staff.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Review call-bell technology, provide appropriate equipment access, and deploy care managers during busy periods to reduce response times.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Issue a significant-learning briefing on call-bell response times and policy adherence.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Reconfigure the call-bell system to escalate unanswered calls after three minutes to an emergency tone.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Embed revised call-bell procedures in staff briefings and induction training.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Greater Manchester West
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 concerns
Each 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
Action
Separate vulnerable and non-vulnerable prisoners across two induction wings.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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 ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Herefordshire
Concerns raised1
Unsatisfactory procedures for establishing whether call bells are working
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 concerns
Each 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
Action
Implement a standardised process and frequency for checking inpatient call bells and reporting faults.
Stated by Wye Valley NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Action
Add digital call-bell check prompts and establish weekly housekeeper call-bell checks.
Stated by Wye Valley NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
Norfolk
Concerns raised1
Failure to assess patients’ ability to use a call bell and provide suitable alternatives when they cannot
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Yorkshire (Western)
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Inadequate processes to ensure patient call-bells are working at all times
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 concerns
Each 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
Action
Implement revised call-bell, oxygen and suction checking through a safety checklist, standard operating procedure and auditable oversight.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
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Includes deficiencies in call bell or emergency cell bell systems and their dedicated controls where the failure could prevent a person from summoning assistance, obscure or misrepresent a call, or delay an appropriate response.
