Recurring concern

Failure to ensure emergency services have reliable, timely access to shared accommodation

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First reported 6 Feb 2018•Latest report 15 Mar 2023

Definition

What this concern includes

Includes failures of the end-to-end emergency-access system for shared or communal accommodation, including access-control equipment, emergency override arrangements, access information, responsible procedures and dedicated staff training where these prevent or delay emergency-service entry.

Not included

  • Generic failures in training, documentation, staffing or communication not explicitly tied to emergency access to shared or communal accommodation.
  • Routine access-control or door-security deficiencies that do not concern emergency-service entry.
  • Access failures involving private dwellings, workplaces, vehicles or other settings without a shared or communal accommodation context.
  • Failures in resident care, alarm response or clinical communication that do not prevent or delay emergency-service access.
Reports
4

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2018–2023

First to latest report issue date

Stated actions
7

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.

Bournemouth Churches Housing Association Limited1
Dorset Police1
FirstPort Retirement Property Services Limited1
Nottinghamshire Healthcare NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Dorset

    AI-generated summary

    Tarik Roger Drakes · 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

    Tarik Roger Drakes, who had a history of using heroin, was found collapsed and unresponsive at his supported accommodation on 12 November 2022. He was taken to hospital, where he was found to be in multi-organ failure, and died on 29 November 2022. Concerns were raised about staffing, welfare checks, monitoring, supervision, safeguarding, emergency access, and follow-up of his support needs at the accommodation.

    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

    Unavailability of a functioning out-of-hours emergency access route

    Wider context from the report

    “1. During the inquest evidence was heard that: i. Dorset Lodge is a supported housing accommodation facility with 16 rooms that provides accommodation for those who have drug and alcohol addictions. It is owned and managed by Bournemouth Churches Housing Association (BCHA) and they are contracted to provide the housing to residents by BCP Council. It is staffed Monday to Friday, between 8am to 8pm by two support workers, one covering a shift from 8am to 4pm and the other covering a shift from 12noon to 8pm. When the support staff are unavailable, agency staff will cover the support worker role. On Saturdays a support worker is present, but this is not on a contracted basis and if she is on leave there is no cover. Outside the hours of 8am to 8pm, and on weekends, when there is no support worker on site, there is a night response team who will not be on site but attend twice during the night period to conduct perimeter checks of the building. The premises is covered by CCTV, inside and outside, which can be monitored remotely. ii. To provide support to the residents, the support workers will undertake key worker sessions which are offered weekly. When agency staff cover the shifts, when the usual support workers are covering other sites or on leave, they do not undertake key worker sessions. iii. Entry to the premises is gained using a key fob system. Entry is monitored by staff when on site, but between 8pm and 8am, and at weekends when no staff members are on site, residents are able to let people in without any monitoring or safeguarding measures in please. iv. Evidence was given that those at Dorset Lodge are vulnerable due to their addictions. Mr Drakes’ family gave evidence that he had disclosed to them that residents were using drugs within the premises, and they described the times when staff were not present as “party time” with non-residents entering the premises. Even when staff are on duty there is no monitoring of who is in the premises, such as by a signing in and out book. Staff undertake welfare checks upon residents 3 times a day at 10.30am, 3.30pm and 7.30pm, however evidence was given that it is not clear who is present at any one time. v. When the police attended Room 14 at Dorset Lodge on the Thursday 17th November, items of drug paraphernalia were found in the room including needles, a sharps box and a homemade pipe. The room had been insecure from 12th November when Mr Drakes was taken to hospital and there was evidence people had been in the room after that time as items had been removed from the room and residents called the Police to report concerns. vi. Evidence was given by the family that when they attended the premises on the 14th November they tried to call the number on the front door, which was out of hours number, and it was a dead line. Unless a resident allows someone entry, this would be the only route of access to Dorset Lodge by emergency services, such as the paramedics, out of staffed hours to provide care in an emergency, which could delay entry and access to treatment. vii. Mr Drakes was last seen alive on CCTV at Dorset Lodge at 0.44 hours on the 12th November. Paramedics were called at 16.07 hours that day by other residents. As this was a Saturday, and the support worker who did work some Saturdays was not working that day, there were no welfare checks undertaken upon him by staff. It is not possible to say what would have happened if he had been checked by staff or taken to hospital sooner. viii. Mr Drakes was deemed to be vulnerable by the manager at Dorset Lodge and there were professional meetings held to discuss, amongst other things, his placement and need for 24 hour support. The last of these professional meetings was held on the 10th August 2022. One was scheduled for the 9th September 2022 but no one was available and the meeting was not rescheduled prior to the 12th November. There was no follow up meeting about his needs after the meeting on the 9th September did not go ahead. 2. I have concerns with regard to the following: i. That there could be the death of a resident at Dorset Lodge under the current processes in place regarding the monitoring, supervision and safeguarding of residents at Dorset Lodge and I would request that consideration is given to reviewing the current levels of staffing and supervision at the placement, and the processes and procedures in place around support to the residents. ”

    Source location

    Tarik Roger Drakes · Prevention of Future Deaths report
    Page 1 · 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

    Remind customers across the housing stock how to contact out-of-hours services and improve related signage.

    Verbatim wording from the response

    “We have discussed OOH arrangements with customers again and asked that they contact OOH Repairs and Maintenance or NRT if there are any incidents during the evenings and weekends. We will also be doing more work to remind customers of how to get in touch out of hours across all of our stock. Signage has been further improved in the reception area of Dorset Lodge to this effect.”

    Source location

    Response from BCHA
    Page 7 · response
    Published 22 March 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

    Free access to the building cannot be provided for emergency services because of security requirements; remote or resident-enabled access is used instead.

    Verbatim wording from the response

    “As with all HMO’s and unstaffed properties, customers can let emergency services in if needed. There is a pad on the front door to call through to other homes. It would not be possible to allow free access into the building for security reasons. This would not be a unique situation for emergency services and is reflective of other HMOs/Apartments without staff or security on site. Dorset Lodge is able to be opened remotely by NRT also if they are contacted and are available.”

    Source location

    Response from BCHA
    Page 7 · response
    Published 22 March 2023

    Open published response

  2. Nottinghamshire

    AI-generated summary

    Michelle Whitehead · 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

    Michelle Whitehead died on 7 May 2021 from a hypoxic brain injury after experiencing deterioration in her breathing and oxygen saturation while detained under Section 2 of the Mental Health Act. The report identifies concerns about unclear sedation medication and documentation, delayed recognition and treatment of her deterioration, lack of medical and consultant involvement, difficulty contacting the duty doctor, and delays in calling and admitting paramedics.

    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 paramedics gaining access to the ward

    Wider context from the report

    “1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation 2. Delayed recognition of Mrs Whitehead’s declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in Paramedics gaining access to the ward Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view. ”

    Source location

    Michelle Whitehead · 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

    Add an Emergency Services Liaison Responder to each ward shift to meet and escort emergency services, with compliance audits reported to senior management.

    Verbatim wording from the response

    “The Directorate has reviewed the formation and functioning of the Incident Response Team and now added the allocation of an Emergency Services Liaison Responder for each ward. This role is allocated to each ward by the nurse in charge as part of every handover at the start of each new shift. This individual functions within the team during normal incident scenarios, however, when a medical emergency is identified, they will immediately go to the main reception, wait for the emergency services to attend, and will escort them immediately to the casualty. This role will also be used in the event of Police or Fire Service support being required and will be allocated to a named individual each shift.”

    Source location

    2022-0016-Response-from-Nottinghamshire-Healthcare_Published
    Page 7 · response
    Published 24 January 2022

    Open published response

  3. Dorset

    AI-generated summary

    Cherylan CLULOW · 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

    Cherylan Clulow was found semi-conscious at home after police were initially unable to gain access beyond the communal door, and she died in hospital on 30 August 2019 following extensive and multiple strokes. The substantive concerns related to delays in accessing shared accommodation during emergencies, including the lack of formal information, training, and general distribution of fire drop keys or key fobs to police officers.

    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 provide Police Officers with reliable emergency access to shared accommodation

    Wider context from the report

    “(1) The Police Officers who were tasked with the initial attendance could not gain access beyond the communal doors. (2) The Police Officers did not believe it was proportionate (based on the information which they had) to force entry through the communal doors which required specialist input. They were aware that a colleague had purchased for himself a fire drop key (to be used in emergency situations which could be used to override the communal lock door. There was a delay in gaining access to the address of the deceased. (3) The Police Officers had no formal information as to where they could source a fire drop key. There was no knowledge of formal steps to be taken to access to a fire drop key particularly as access to communal properties is that more difficult to gain. (4) There appears to be no general distribution of such keys or key fobs to Dorset Police Officers in order to gain access to shared accommodation by officers in an emergency situation 24 hours a day, 365 days per year. (5) There appears to be no training or dissemination of information as to how such keys can be obtained. ”

    Source location

    Cherylan CLULOW · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Lack of general distribution of fire drop keys or key fobs to Police Officers

    Wider context from the report

    “(1) The Police Officers who were tasked with the initial attendance could not gain access beyond the communal doors. (2) The Police Officers did not believe it was proportionate (based on the information which they had) to force entry through the communal doors which required specialist input. They were aware that a colleague had purchased for himself a fire drop key (to be used in emergency situations which could be used to override the communal lock door. There was a delay in gaining access to the address of the deceased. (3) The Police Officers had no formal information as to where they could source a fire drop key. There was no knowledge of formal steps to be taken to access to a fire drop key particularly as access to communal properties is that more difficult to gain. (4) There appears to be no general distribution of such keys or key fobs to Dorset Police Officers in order to gain access to shared accommodation by officers in an emergency situation 24 hours a day, 365 days per year. (5) There appears to be no training or dissemination of information as to how such keys can be obtained. ”

    Source location

    Cherylan CLULOW · 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

    Procure and issue keys and fobs to all frontline officers for emergency access to local-authority communal buildings.

    Verbatim wording from the response

    “Accordingly, the decision has been made that all frontline Dorset Police officers will now carry keys and fobs when on duty. It is my view that this will serve to avoid delays in sourcing such items and allow for quick access to relevant properties in emergency situations. The process of procuring these items is already underway and I understand that they can be issued to frontline officers quickly (and, I believe, within a month).”

    Source location

    2021-0009-Response-from-Dorset-Police-Redacted
    Page 2 · response
    Published 14 January 2021

    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

    Identify vulnerable residents in privately owned communal premises, obtain relevant keys and fobs, and store access arrangements locally with linked incident-management instructions.

    Verbatim wording from the response

    “To compensate for this, we are in the process of identifying specific vulnerable individuals who live in similar but privately-owned communal premises, with a view to obtaining the relevant keys and fobs to facilitate access to those specific properties where required. Due to the volume of such items, where privately-owned premises are concerned we will store the relevant keys and fobs in a police station local to the address in question, and link instructions for obtaining the relevant item to the record that we hold for the vulnerable individual in question on our police incident management system.”

    Source location

    2021-0009-Response-from-Dorset-Police-Redacted
    Page 2 · response
    Published 14 January 2021

    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

    Circulate a reminder to frontline officers on police powers of entry, including lawful forced entry in relevant emergencies.

    Verbatim wording from the response

    “It is my understanding that the keys and fobs are extremely simple to use; essentially, they function as a key. Accordingly, no training should be required. I can however confirm that a reminder on police powers of entry will be circulated to all frontline officers in due course, including on the organisation’s intranet. This will be used as an opportunity to remind frontline police officers of powers available to the police in terms of forcing entry to properties in situations such as that encountered by the colleagues who attended Cheralyn’s address prior to her death.”

    Source location

    2021-0009-Response-from-Dorset-Police-Redacted
    Page 2 · response
    Published 14 January 2021

    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 variety and volume of keys and fobs make sourcing every item for privately owned premises unrealistic.

    Verbatim wording from the response

    “Our enquiries have led us to conclude that the sheer variety of such items used in privately-owned properties would mean that it is difficult (to the point of being unrealistic) to source every such item. In simple terms, I understand that there is no such item as a ‘skeleton key’ in this context. In this respect, it is of note that, as I understand it, the fire service do not carry or have access to such items on a similar basis, and will instead force entry to such addresses when required.”

    Source location

    2021-0009-Response-from-Dorset-Police-Redacted
    Page 2 · response
    Published 14 January 2021

    Open published response

  4. Bedfordshire and Luton

    AI-generated summary

    MAVIS JEANNE REVES · 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

    On 1 July 2017, Mavis Jeanne Reves pulled her Careline cord because she had a dry mouth and was struggling to breathe. Paramedics reached her flat after delays involving the building’s automated entry system and key safe, and performed CPR. The concerns included limitations of the analogue Careline system, delays in emergency access and connection time, and difficulties identifying the master key.

    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 the analogue Careline system to support concurrent emergency access and calls

    Wider context from the report

    “(1) At the Inquest it was revealed that there are 4 ways a non-resident can enter the building: (a) By entering the room number on the keypad (b) By using a code (c) By pressing 2 buttons, namely “clear” and then “call” (d) By being allowed in by a resident that was passing through the entrance The deceased did not answer the call; the code was not available to the paramedic, who had arrived before it was forwarded to his car’s computer. In any event that which arrived was probably not the correct code. The “call” button is supposed to connect to the Emergency Call Centre, but will not connect if the Careline has been pulled. In this case, the fact that the deceased was still talking to the Careline Operator meant that option (c) above was not available to the paramedic. This is because the system in place is an analogue system and there is only one line going from the building to Careline. Evidence was heard that only 3% of Careline calls result in 999 being called. The remaining 97% are non-urgent calls, accidental calls and calls by residents who are lonely. This means that access using option (c) could be deprived by anyone else in the building using the system. Further it means that once one resident is using the system that no other resident can call the Careline, even if there is an emergency. The scenario of a resident calling the Careline in an emergency and staying on the line is understandable and cannot be that unusual. It appears that a digital system would avoid these problems. It is understood that for a digital system to be installed the residents must agree to fund it, and that would then form part of the service charge. My concern is twofold. First, do the residents know of the limitation within the Careline System currently installed? Secondly, in the absence of an upgrade to digital, plans need to be put in place so that the emergency services can gain access without undue delay. (2) The Inquest heard that the analogue system takes 90 seconds to connect. The reason for this is because it is also sending data relating to the Careline Operator’s Terminal. A digital system would reduce that to 4 seconds. My concern again is whether the residents know this. In cases where promptness is important 90 seconds can be the difference between life and death. ”

    Source location

    MAVIS JEANNE REVES · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Failure to ensure emergency services can gain building access without undue delay

    Wider context from the report

    “(1) At the Inquest it was revealed that there are 4 ways a non-resident can enter the building: (a) By entering the room number on the keypad (b) By using a code (c) By pressing 2 buttons, namely “clear” and then “call” (d) By being allowed in by a resident that was passing through the entrance The deceased did not answer the call; the code was not available to the paramedic, who had arrived before it was forwarded to his car’s computer. In any event that which arrived was probably not the correct code. The “call” button is supposed to connect to the Emergency Call Centre, but will not connect if the Careline has been pulled. In this case, the fact that the deceased was still talking to the Careline Operator meant that option (c) above was not available to the paramedic. This is because the system in place is an analogue system and there is only one line going from the building to Careline. Evidence was heard that only 3% of Careline calls result in 999 being called. The remaining 97% are non-urgent calls, accidental calls and calls by residents who are lonely. This means that access using option (c) could be deprived by anyone else in the building using the system. Further it means that once one resident is using the system that no other resident can call the Careline, even if there is an emergency. The scenario of a resident calling the Careline in an emergency and staying on the line is understandable and cannot be that unusual. It appears that a digital system would avoid these problems. It is understood that for a digital system to be installed the residents must agree to fund it, and that would then form part of the service charge. My concern is twofold. First, do the residents know of the limitation within the Careline System currently installed? Secondly, in the absence of an upgrade to digital, plans need to be put in place so that the emergency services can gain access without undue delay. (2) The Inquest heard that the analogue system takes 90 seconds to connect. The reason for this is because it is also sending data relating to the Careline Operator’s Terminal. A digital system would reduce that to 4 seconds. My concern again is whether the residents know this. In cases where promptness is important 90 seconds can be the difference between life and death. ”

    Source location

    MAVIS JEANNE REVES · 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

    Ensure Appello Careline systems display the correct access codes for each managed development to operators.

    Verbatim wording from the response

    “2.4.2 The error was due to the Appello Careline Operator not being aware of the correct code required for the particular type of Tunstall installed. This was formally raised with the Monitoring Services Director at Appello Careline and a joint review, with ourselves, was undertaken to ensure that all of their systems contained the correct numbers/codes for all of the developments that we manage and for which they provide this service. We have ensured that the correct codes are now contained on their system and that all operators at Appello Careline will see the correct codes when they connect to a specific development.”

    Source location

    2018-0035-Response-by-FirstPort-Retirement
    Page 2 · response
    Published 7 June 2018

    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

    Store the master key separately and prominently within the entrance key safe.

    Verbatim wording from the response

    “2.4.3 Further, as set out in paragraph 4.1 the master key is now individually stored to ensure ease of access for any emergency services.”

    Source location

    2018-0035-Response-by-FirstPort-Retirement
    Page 2 · response
    Published 7 June 2018

    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

    Safelink would not provide emergency access because its rotating codes require prior registration and the system was not designed for emergency-service entry.

    Verbatim wording from the response

    “(a) Firstly, we looked into installing Safelink at the premises, which is a system for enabling access to the building for carers visiting a residential premises and a further service offered by Appello Carline. They have confirmed however that this is a rotating code, which they issue and which changes regularly and therefore it would not allow emergency services to access the building without first registering for a code. The system was not designed for”

    Source location

    2018-0035-Response-by-FirstPort-Retirement
    Page 2 · response
    Published 7 June 2018

    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

    An additional emergency telephone line would not improve access because the existing gate number directly connects to the careline with emergency priority.

    Verbatim wording from the response

    “(b) Secondly, we looked into installing an emergency telephone line at the entry gate. Appello Careline has confirmed however that the number provided at the front gate is an emergency number that connects direct to them and is treated with the same priority and urgency as a fire call at the residence. Again, this would not therefore add a further method of entry for the emergency services.”

    Source location

    2018-0035-Response-by-FirstPort-Retirement
    Page 3 · response
    Published 7 June 2018

    Open published response
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Data last updated 7 September 2026