Recurring concern

Unreliable hospital emergency-power controls

Pin Get email alerts Request correction

First reported 17 Mar 2016•Latest report 21 Jul 2025

Definition

What this concern includes

Includes hospital controls for detecting, indicating, communicating, isolating, restoring or locally resetting emergency-power and related mains-power failures where loss of power can disrupt clinical treatment, equipment or patient safety, including EPO status indication and reset arrangements and alerts for local mains-power failure.

Not included

  • Excludes ordinary electrical maintenance or equipment faults that are not part of hospital emergency-power detection, control or restoration arrangements.
  • Excludes generic clinical escalation, staffing or communication failures unless they directly impair hospital emergency-power controls.
  • Excludes failures of non-hospital power systems and routine building power use where no patient-safety consequence or emergency-power control is identified.
  • Excludes downstream clinical treatment delays after emergency power has been reliably detected and restored.
Reports
2

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2016–2025

First to latest report issue date

Stated actions
5

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.

Department of Health and Social Care1
Health and Safety Executive1
NHS England1
Philips Electronics UK Limited1
St George'S University Hospitals 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. Greater Lincolnshire

    AI-generated summary

    Jean DYE · 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

    Jean Dye died at Scunthorpe General Hospital after an artery dissection during a cardiac procedure, followed by an unexpected electrical power failure that delayed emergency stenting for approximately 10 minutes. The principal concerns were that activation of the Emergency Power Off circuit overrode backup power, there was no indicator or local reset control in the treatment room, and guidance on the location of such controls and related training may require review.

    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 an in-room EPO circuit reset control

    Wider context from the report

    “The circumstances of Mrs Dye's death are set out above. Her death arose as a consequence of the combination of an iatrogenic injury sustained during a clinical procedure and an untimely loss of power to the Catheter Lab where she was being treated for a period of approximately ten minutes at exactly the time at which her treating consultant required the benefits of real time x ray to facilitate a necessary emergency stenting procedure. The delay whilst power was restored was a critical factor in this death. The loss of power arose as a result of the Emergency Power Off (EPO) circuit activating. It overrode the emergency power back up system. The reason for that activation was unclear although a physical activation of any of the three EPO buttons was excluded on the evidence. All staff at the scene were unaware of the cause of the loss of power, never having experienced such a situation previously, and an engineer was summoned to attend to reinstate the power, which he did. There was no light or other indicator within the lab to confirm to those present that the EPO circuit had activated. Likewise there was no restart button within the lab to permit the EPO circuit to be reset. That lay within the plant room elsewhere within the hospital. I received evidence of a small number of accidental activations of EPO circuits nationally over a 12 month period. It is plainly something which can, and does, occur. Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who inturn had to attend a separate plant room, the downtime would likely have been significantly reduced. Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical. I received evidence that there is no current guidance in relation to the siting of such controls remote from the affected room. I invite review of that guidance and of the need for any consequential training. ”

    Source location

    Jean DYE · 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 guidance on remote siting of Emergency Power Off controls

    Wider context from the report

    “The circumstances of Mrs Dye's death are set out above. Her death arose as a consequence of the combination of an iatrogenic injury sustained during a clinical procedure and an untimely loss of power to the Catheter Lab where she was being treated for a period of approximately ten minutes at exactly the time at which her treating consultant required the benefits of real time x ray to facilitate a necessary emergency stenting procedure. The delay whilst power was restored was a critical factor in this death. The loss of power arose as a result of the Emergency Power Off (EPO) circuit activating. It overrode the emergency power back up system. The reason for that activation was unclear although a physical activation of any of the three EPO buttons was excluded on the evidence. All staff at the scene were unaware of the cause of the loss of power, never having experienced such a situation previously, and an engineer was summoned to attend to reinstate the power, which he did. There was no light or other indicator within the lab to confirm to those present that the EPO circuit had activated. Likewise there was no restart button within the lab to permit the EPO circuit to be reset. That lay within the plant room elsewhere within the hospital. I received evidence of a small number of accidental activations of EPO circuits nationally over a 12 month period. It is plainly something which can, and does, occur. Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who inturn had to attend a separate plant room, the downtime would likely have been significantly reduced. Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical. I received evidence that there is no current guidance in relation to the siting of such controls remote from the affected room. I invite review of that guidance and of the need for any consequential training. ”

    Source location

    Jean DYE · 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

    Accidental activation of Emergency Power Off circuits overriding emergency power backup systems

    Wider context from the report

    “The circumstances of Mrs Dye's death are set out above. Her death arose as a consequence of the combination of an iatrogenic injury sustained during a clinical procedure and an untimely loss of power to the Catheter Lab where she was being treated for a period of approximately ten minutes at exactly the time at which her treating consultant required the benefits of real time x ray to facilitate a necessary emergency stenting procedure. The delay whilst power was restored was a critical factor in this death. The loss of power arose as a result of the Emergency Power Off (EPO) circuit activating. It overrode the emergency power back up system. The reason for that activation was unclear although a physical activation of any of the three EPO buttons was excluded on the evidence. All staff at the scene were unaware of the cause of the loss of power, never having experienced such a situation previously, and an engineer was summoned to attend to reinstate the power, which he did. There was no light or other indicator within the lab to confirm to those present that the EPO circuit had activated. Likewise there was no restart button within the lab to permit the EPO circuit to be reset. That lay within the plant room elsewhere within the hospital. I received evidence of a small number of accidental activations of EPO circuits nationally over a 12 month period. It is plainly something which can, and does, occur. Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who inturn had to attend a separate plant room, the downtime would likely have been significantly reduced. Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical. I received evidence that there is no current guidance in relation to the siting of such controls remote from the affected room. I invite review of that guidance and of the need for any consequential training. ”

    Source location

    Jean DYE · 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 in-room indication of Emergency Power Off circuit activation

    Wider context from the report

    “The circumstances of Mrs Dye's death are set out above. Her death arose as a consequence of the combination of an iatrogenic injury sustained during a clinical procedure and an untimely loss of power to the Catheter Lab where she was being treated for a period of approximately ten minutes at exactly the time at which her treating consultant required the benefits of real time x ray to facilitate a necessary emergency stenting procedure. The delay whilst power was restored was a critical factor in this death. The loss of power arose as a result of the Emergency Power Off (EPO) circuit activating. It overrode the emergency power back up system. The reason for that activation was unclear although a physical activation of any of the three EPO buttons was excluded on the evidence. All staff at the scene were unaware of the cause of the loss of power, never having experienced such a situation previously, and an engineer was summoned to attend to reinstate the power, which he did. There was no light or other indicator within the lab to confirm to those present that the EPO circuit had activated. Likewise there was no restart button within the lab to permit the EPO circuit to be reset. That lay within the plant room elsewhere within the hospital. I received evidence of a small number of accidental activations of EPO circuits nationally over a 12 month period. It is plainly something which can, and does, occur. Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who inturn had to attend a separate plant room, the downtime would likely have been significantly reduced. Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical. I received evidence that there is no current guidance in relation to the siting of such controls remote from the affected room. I invite review of that guidance and of the need for any consequential training. ”

    Source location

    Jean DYE · 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

    Amend HBN 06-01 to address emergency-stop button locations and incorporate the discussed changes to EPO guidance.

    Verbatim wording from the response

    “Earlier guidance, published in 2001 by the former NHS Estates (an Executive Agency of DHSC abolished in 2005) called HBN 06-01 “Facilities for diagnostic imaging and interventional radiology” is in the process of being updated, but excludes cardiac facilities covered separately in HBN 01-01. The draft updated HBN 06-01 currently includes the following text on EPO buttons:”

    Source location

    Response from NHS England
    Page 3 · response
    Published 13 August 2025

    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

    Update HTM 06-01, reviewing EPO content against the incident and HBN 06-01 to align the final guidance.

    Verbatim wording from the response

    “This guidance is focused on stopping accidental activation of the EPO, but does not currently state what to do if the EPO is activated in error. The NHS England Estate’s team advise that they will address this when the HTM 06-01 guidance document is next updated.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 13 August 2025

    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 EPO control need not be located in the equipment room; a means to reset it is sufficient, subject to a room-design risk assessment.

    Verbatim wording from the response

    “NHS England’s Head of Hard Facilities Management has been contacted by an independent advisor to the Medicines and Healthcare products Regulatory Agency (MHRA) on electrical safety, who was involved in the inquest hearing. The MHRA advisor raised that:”

    Source location

    Response from NHS England
    Page 2 · response
    Published 13 August 2025

    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

    Setting guidance or associated training requirements falls outside the regulator’s powers, so it cannot respond further on those matters.

    Verbatim wording from the response

    “It is important to highlight from the outset that CQC does not have the power to set guidelines or training expectations, rather we assess a registered provider’s ability to meet regulatory requirements. Whilst assessing regulatory compliance can involve the application of relevant guidelines, it is not within the scope of CQC’s regulatory powers to set the guidelines or associated training requirements.”

    Source location

    Response from Care Quality Commission
    Page 2 · response
    Published 13 August 2025

    Open published response

  2. Inner West London

    AI-generated summary

    Jacqueline Emma Brown Scott · 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

    Jacqueline Emma Brown Scott was admitted to hospital on 31 March 2015 with worsening shortness of breath and reduced mobility and was treated with a BIPAP machine. The machine was running on battery because of a failed power socket, but this was not recognised before the battery ran out; she died shortly afterwards. Concerns included the machine’s battery warnings and alarms, staff training, ward power provision and the absence of systems to identify power failures.

    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 a system or check to alert ward staff to local mains-power failure

    Wider context from the report

    “(vi)There was no system or check that would alert ward staff to the failure of mains power in any particular area. ”

    Source location

    Jacqueline Emma Brown Scott · 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

    Obtain external electrical-infrastructure advice and use it to design Richmond ADU UPS/IPS backup arrangements.

    Verbatim wording from the response

    “The Trust engaged an external expert to advise the organisation on the areas where the electrical infrastructure requires upgrading to comply with HTM 06-01. This advice has”

    Source location

    St-Georges-Hospital-Response
    Page 2 · response
    Published 17 March 2016

    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

    Progress tendering and installation of the Richmond ADU UPS/IPS backup system to alert staff when mains power fails.

    Verbatim wording from the response

    “formed the basis of the design a UPS/ IPS back up system in the Richmond ADU area. The work has now been put to a tender process with the summer 2016 set as the date for completion of this work due to the co-ordination that is required with clinical areas for this work to be completed. The Trust has set aside sufficient funds for this work to be completed and once installed the designed UPS/IPS back up system will alert staff of any failure in the electricity supply to the mains sockets.”

    Source location

    St-Georges-Hospital-Response
    Page 3 · response
    Published 17 March 2016

    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

    Consider the adequacy of HTM guidance on alerts relating to power-supply interruptions.

    Verbatim wording from the response

    “The HTM also provides guidance on the provision of audible and visual alarms in relation to interruptions to power supply failures and the need to provide indication at the nurse’s station for the relevant medical area.”

    Source location

    2016-0112-Response-by-Department-of-Health
    Page 4 · response
    Published 17 March 2016

    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

    Existing HTM guidance is considered adequate regarding alerts for interruptions to power supply.

    Verbatim wording from the response

    “The HTM also provides guidance on the provision of audible and visual alarms in relation to interruptions to power supply failures and the need to provide indication at the nurse’s station for the relevant medical area.”

    Source location

    2016-0112-Response-by-Department-of-Health
    Page 4 · response
    Published 17 March 2016

    Open published response
Back to top

Data last updated 7 September 2026