4 Apr 2025 Mr YZ · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Failure of careline guidelines to accommodate users with impaired communication and cognitive processing View source
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Mr YZ · 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
Mr YZ died at home on 2 March 2024 from extensive blood loss following a traumatic open fracture of the right ankle. He activated his emergency careline but did not receive medical assistance after the operator treated the brief call as accidental. The principal concern was that careline procedures and questioning may fail to identify serious injury in users with impairments similar to those associated with Huntington’s Disease.
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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 careline guidelines to accommodate users with impaired communication and cognitive processing
Wider context from the report “(1) YZ’s presentation with Huntington’s Disease involved altered pain pathways/responses, slurred speech, lack of or reduced insight, tendency to apathy and self-neglect and impaired cognitive processing.
(2) These are aspects of presentation that may be present in a wider group of other end-users of careline services (for example those with dementia) and are not limited to end-users with Huntington’s Disease.
(3) I found there was a missed opportunity to obtain life-saving medical assistance that was attributable to YZ’s impairments arising from Huntington’s Disease.
(4) YZ had called for assistance but the operator failed to identify that he had a major injury with significant blood loss.
(5) The interaction was very brief, YZ contributing only a few words, and I found key information might have been elicited if YZ had been given more time, asked to repeat his unintelligible opening words, or had been asked open and/or more specific closed questions.
(6) I found the operator who answered the call was trained and had followed the protocols that were in place for him at that time. He was not a clinician. His management of the call was in line with the guidelines applicable to his work (Appello Careline Limited guidelines, and the guidelines of the Telecare Services Association, which are followed by most of the careline services industry).
(7) After YZ’s death Appello Careline Limited quickly and proactively reviewed their procedures and amended their call protocols. At inquest they accepted the offer of the Huntington’s Disease Association to work with them to identify questioning methods or protocols that might further reduce the risk of similar outcomes in future.
(8) The Telecare Services Association was not a recognised interested person in YZ’s inquest.
(9) I am bringing a risk formally to their attention with this report. The risk is to careline users with similar presentations as YZ if the Telecare Services Association’s guidelines continue unamended.
” Source location Mr YZ · 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 learning from the report during the next QSF scheme change to inform stronger criteria and refined TEC operator questioning techniques.
Verbatim wording from the response “As part of our next QSF scheme change process, we will review the learning from this report to further strengthen criteria for all QSF certified organisations. A key focus will be on refining questioning techniques for TEC Operators when handling alarm calls, ensuring improved accuracy and responsiveness. This will also include the review of programme two, alongside contributions from the TEC Sector and external stakeholders, of the TEC Quality CPD mandatory workforce training for all frontline TEC staff and a review of the ‘Decision Support Tool’ for TEC Operators.” Source location Response from The Telecare Services Association
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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 programme two of the TEC Quality mandatory CPD workforce training with TEC sector and external stakeholder contributions.
Verbatim wording from the response “As part of our next QSF scheme change process, we will review the learning from this report to further strengthen criteria for all QSF certified organisations. A key focus will be on refining questioning techniques for TEC Operators when handling alarm calls, ensuring improved accuracy and responsiveness. This will also include the review of programme two, alongside contributions from the TEC Sector and external stakeholders, of the TEC Quality CPD mandatory workforce training for all frontline TEC staff and a review of the ‘Decision Support Tool’ for TEC Operators.” Source location Response from The Telecare Services Association
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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 the Decision Support Tool for TEC operators as part of the QSF scheme change process.
Verbatim wording from the response “As part of our next QSF scheme change process, we will review the learning from this report to further strengthen criteria for all QSF certified organisations. A key focus will be on refining questioning techniques for TEC Operators when handling alarm calls, ensuring improved accuracy and responsiveness. This will also include the review of programme two, alongside contributions from the TEC Sector and external stakeholders, of the TEC Quality CPD mandatory workforce training for all frontline TEC staff and a review of the ‘Decision Support Tool’ for TEC Operators.” Source location Response from The Telecare Services Association
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6 Jun 2024 Anoush Summers · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Lack of a clear allocation of duties and responsibilities for reporting wrist-alarm faults 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
Anoush Summers · 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
Anoush Summers, a frail woman living alone, fell at home after her wrist alarm had been reported as broken and was found the following day. She was taken to hospital and died of hypothermia on 14 January 2024. Concerns included the failure to repair or replace the alarm, unclear reporting responsibilities, and inadequate instructions or training for carers regarding alarm faults and care notes.
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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 Lack of a clear allocation of duties and responsibilities for reporting wrist-alarm faults
Wider context from the report “6. There was no clear system identified between the company providing carers and the local authority , as to the duties and responsibilities of each in the reporting of faults with wrist alarms .
” Source location Anoush Summers · 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 Report faulty pendants to the responsible telecare provider and commissioning local authority.
Verbatim wording from the response “notified to the local authority so they can take primacy to act and ensure that a repair or an alternative is commissioned.” Source location Response from Supreme Care Services Ltd
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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 Supplying, maintaining, repairing or replacing faulty pendants falls outside the domiciliary care provider’s role and contractual requirements.
Verbatim wording from the response “4. The telecare provider ought to have been aware that the pendant was not working through its own testing.” Source location Response from Supreme Care Services Ltd
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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 The telecare provider is responsible for supplying, routinely testing, monitoring, maintaining, repairing and replacing faulty pendants.
Verbatim wording from the response “16. It remains the role of the telecare provider to monitor and replace any faulty pendants within the terms of its contractual arrangements with the funding authority and it is also their responsibility to routinely test pendants.” Source location Response from Supreme Care Services Ltd
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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 The local authority should take primacy to act and ensure repair or an alternative is commissioned for faulty pendants.
Verbatim wording from the response “notified to the local authority so they can take primacy to act and ensure that a repair or an alternative is commissioned.” Source location Response from Supreme Care Services Ltd
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4 Oct 2022 Reginald Cauthery · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Failure to review telecare services in light of increased fire risk and deteriorating mobility View source Failure to answer telecare fire calls as a priority View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission Department of Health and Social Care TEC Services Association C.I.C.
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
Department of Health and Social Care
Publish the “What Good Looks Like” framework, including guidance for local authorities on considering technology-enabled care and linked preventative devices.
View source
Department of Health and Social Care
Issue an updated Adult Social Care Digital Skills Framework supporting workforce training and regular review of technology use in care plans.
View source
TEC Services Association C.I.C.
Develop the British Standard for technology-enabled care assessment, risk, design, installation and maintenance through BSI committee work.
View source
TEC Services Association C.I.C.
Implement the completed British Standard’s requirements within the Quality Standards Framework and audit certified installation companies against them.
View source
TEC Services Association C.I.C.
Commence development of a Fire Call Handling Pathway Decision Support Tool after completing the Ambulance tool, with NFCC and LFB support if available.
View source See 2 more actions
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AI-generated summary
Reginald Cauthery · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Reginald Cauthery was a frail man with limited mobility who lived alone and died in hospital after sustaining extensive burns in a smouldering fire at his flat. The report raised concerns that his telecare service was not reviewed despite his increased fire risk and deteriorating mobility, and that his smoke alarms were not connected to the telecare system, delaying contact with the Fire Brigade.
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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 review telecare services in light of increased fire risk and deteriorating mobility
Wider context from the report “(1) There was no review of the telecare service provided to Mr Cauthery despite the agencies working with him being aware of his increased fire risk and deteriorating mobility .
” Source location Reginald Cauthery · Prevention of Future Deaths report
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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 answer telecare fire calls as a priority
Wider context from the report “(3) If Mr Cauthery’s smoke alarm had been connected to his telecare system, the call would have been answered as a priority . In addition, the call handler would not have spent several minutes seeking confirmation that the smoke alarm was going off before making a 999 call.
” Source location Reginald Cauthery · Prevention of Future Deaths report
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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 Publish the “What Good Looks Like” framework, including guidance for local authorities on considering technology-enabled care and linked preventative devices.
Verbatim wording from the response “This Department published the “What Good Looks Like” framework for adult social care on 16 May. It is available on GOV.UK. The framework has been developed as part of Department of Health and Social Care and NHS England guidance to support health and care organisations with digitisation. The What Good Looks Like framework aims to bring together the needs of local authorities and care providers into one coherent guidance document that helps them to understand what they need to do to work well digitally.” Source location Response from Department of Health and Social Care
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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 Issue an updated Adult Social Care Digital Skills Framework supporting workforce training and regular review of technology use in care plans.
Verbatim wording from the response “Also issued on 16 May by this Department was an updated Adult Social Care Digital Skills Framework to help support the development of digital skills across the adult social care workforce. It can be used by social care employers to help with planning staff training, or by individuals for their personal development. This updated framework will support social care workers to understand the importance of, and develop the skills to regularly review, how technology is used to support care within people’s care plans. Further information can be found at www.digitalsocialcare.co.uk/digital-skills-and-training/digital-skills-framework.” Source location Response from Department of Health and Social Care
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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 Develop the British Standard for technology-enabled care assessment, risk, design, installation and maintenance through BSI committee work.
Verbatim wording from the response “In addition, TSA represents the TEC sector on British Standards Institute (BSI) working committees, to develop standards in public safety in TEC. We are currently working on a new British Standard with one of these committees, which will be called “BS 8684 - Technology enabled care – Assessment of user needs and risks, system design, installation and maintenance – Code of practice” and is aimed to specifically reduce the risks identified in this case. This development work will likely continue into 2023, but when it is complete, we will also be implementing this requirement within our QSF, which our auditors will then audit against to ensure it is implemented by certified TEC installation companies. This inclusion will most likely be achieved in our programmed review in September of next year.” Source location Response from TEC Services Association
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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 the completed British Standard’s requirements within the Quality Standards Framework and audit certified installation companies against them.
Verbatim wording from the response “In addition, TSA represents the TEC sector on British Standards Institute (BSI) working committees, to develop standards in public safety in TEC. We are currently working on a new British Standard with one of these committees, which will be called “BS 8684 - Technology enabled care – Assessment of user needs and risks, system design, installation and maintenance – Code of practice” and is aimed to specifically reduce the risks identified in this case. This development work will likely continue into 2023, but when it is complete, we will also be implementing this requirement within our QSF, which our auditors will then audit against to ensure it is implemented by certified TEC installation companies. This inclusion will most likely be achieved in our programmed review in September of next year.” Source location Response from TEC Services Association
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 Commence development of a Fire Call Handling Pathway Decision Support Tool after completing the Ambulance tool, with NFCC and LFB support if available.
Verbatim wording from the response “Once our work on the Ambulance Pathway Decision Support Tool is complete, we will commence work on a similar tool for Fire Call Handling, with the support of NFCC and LFB if they are willing to do so. It must be recognised that it is likely that such a tool would not be available for use by service providers” Source location Response from TEC Services Association
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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 Telecare and fire-service matters fall outside regulation, leaving no powers to prevent future deaths concerning those services.
Verbatim wording from the response “However, the matters of concerns highlighted in the Regulation 28 report relate to services outside our scope of regulation. We do not regulate the fire service or the” Source location Response from Home Care Quality Commission
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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 Local authorities commissioning telecare services determine contract requirements, including device maintenance and reviewing device use.
Verbatim wording from the response “Telecare services are provided by local authorities, housing associations, the third sector and by commercial organisations. Not all local authorities provide or commission telecare services, but telecare is an intervention linked to the Care Act of 2014 and that Act’s responsibilities of preventing, reducing, or delaying the development of care and support needs or in meeting individual eligible needs for care and support. Where local authorities are commissioning telecare services, they will agree their own contracts in doing so, including how telecare devices should be maintained and their use reviewed.” Source location Response from Department of Health and Social Care
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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 The investigation found no evidence that involved TEC services were specifically at fault, while identifying disjointed agency working as significant.
Verbatim wording from the response “On this occasion and from our discussions, we could not see any evidence that the TEC services involved, were at fault in any specific way, but we do feel that the disjointed way of working between agencies is a significant factor in this case. However, we do believe that lessons can be learnt.” Source location Response from TEC Services Association
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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 Coordination of care and TEC provision should have been undertaken by the commissioning local authority, depending on contractual relationships.
Verbatim wording from the response “• Each agency appears to have been working in accordance with its own individual contractual requirements, but not as a collective of care. I consider that depending on the contractual relationships, this should have been coordinated by LBH as the commissioner of the TEC service and is likely to have assisted in determining the care provision prescribed.” Source location Response from TEC Services Association
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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 A Fire Call Handling Pathway Decision Support Tool is unlikely to be available until 2024 because development, testing, training and evaluation are required.
Verbatim wording from the response “Once our work on the Ambulance Pathway Decision Support Tool is complete, we will commence work on a similar tool for Fire Call Handling, with the support of NFCC and LFB if they are willing to do so. It must be recognised that it is likely that such a tool would not be available for use by service providers” Source location Response from TEC Services Association
Open published response
21 Feb 2022 Sean Ennis · Prevention of Future Deaths report North London
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Concerns raised 3
Lack of compulsory telecare regulation and minimum standards View source Lack of Telecare Services Association accreditation View source Failure to link telecare to smoke alarms or AFSS View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Sean Ennis · 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
Sean Ennis was found in his flat after a fire and died in hospital from the consequences of smoke inhalation. The principal concerns included incomplete fire-risk assessment and inadequate smoke detection and telecare arrangements for a vulnerable resident, including the alarm centre not knowing he was a smoker and not responding when he did not answer calls.
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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 Lack of compulsory telecare regulation and minimum standards
Wider context from the report “2. The London Fire Brigade believe that a review should be undertaken with regards to Telecare legislation and regulations. Currently this is an unregulated area and although there are British Standards and industry guidance, these are not compulsory . Legislation should clearly identify a Local Authority’s or responsible person(s) acting on behalf of the Local Authority’s responsibility to assess vulnerable individuals for telecare. This should include a checklist of factors, which should be assessed at regular intervals, with a clearly defined trigger for recommendation for telecare including linking to smoke detection and personal pendants. Legislation should also ensure minimum standards are enforced, practices are standardised and sanctions are available for serious breaches.
” Source location Sean Ennis · Prevention of Future Deaths report
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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 Lack of Telecare Services Association accreditation
Wider context from the report “4. Barnet Assist are not Telecare Services Association (TSA) accredited , it is recommended that they become accredited. TSA accreditation ensures that companies agree to providing telecare that meets a set of standards, can receive additional training and encourages consistency in the industry. This should positively impact all service users.
” Source location Sean Ennis · Prevention of Future Deaths report
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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 link telecare to smoke alarms or AFSS
Wider context from the report “3. Telecare is not always offered to vulnerable people or if individuals do receive it, is not always linked to smoke alarms or AFSS . Telecare is often at the cost of the individual or Local Authority which may be why a full telecare system is not offered or installed. The Telecare Services Association should consider exploring a sustainable funding source to enable all vulnerable residents in need of telecare to be provided with a full system.
” Source location Sean Ennis · 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 Engage with reviews of telecare legislation and regulations.
Verbatim wording from the response “2) Barnet Homes undertakes to engage and co-operate with any review of telecare legislation and regulations and work to and, where possible, exceed any minimum standards introduced as a result.” Source location 2022-0054-Response-from-Barnet-Homes_Published.pdf
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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 Consider applying for Telecare Services Association accreditation as part of the wider service review.
Verbatim wording from the response “4) Barnet Assist is a member of the TSA, and we are actively considering whether to apply to be accredited as part of an ongoing wider service review which is due to conclude later this year. Barnet Assist already meets or exceeds the TSA targets for both call answering and mobile response.” Source location 2022-0054-Response-from-Barnet-Homes_Published.pdf
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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 Matters of Concern 2, 3 and 4 are not issues for the landlord to address.
Verbatim wording from the response “Matter of Concern 2:” Source location 2022-0054-Response-from-Network-Homes_Published.pdf
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9 Dec 2019 John Michael WELLS · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Failure to transfer important and accurate medical information to telecare and emergency services View source
This report raised 7 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
John Michael WELLS · 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
John Michael Wells died at the scene after lacerating a varicose vein and suffering severe blood loss while prescribed anticoagulant medication. The report identified concerns about incomplete medical information, the accessibility and handling of responder contact details, the absence of automatic risk flagging, and the triage of third-party emergency calls.
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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 transfer important and accurate medical information to telecare and emergency services
Wider context from the report “(1) The information regarding Mr Wells’ medical conditions and medication held by RedAssure/Worthing Homes was not complete.
RedAssure were the providers of the telecare service to Mr Wells and were part of Worthing Homes. RedAssure had contracted Apello to answer out of hours calls.
During the inquest I heard evidence that when a resident moves into Worthing Homes sheltered housing they are asked to provide medical information; as are any persons who happen to accompany them. I heard that updates are requested from the residents by sending out a form.
Neither Worthing Homes nor RedAssure seek permission from the residents to obtain medical information from their GP or other third parties.
I heard evidence that the staff at Worthing Homes had been aware of Mr Wells’ special needs and vulnerability but this did not appear on the resident information sheet; which provides the information accessed by Appello.
Whilst I heard evidence that Worthing Homes are no longer providing telecare support they still provide the medical information recorded on their residents to telecare providers.
Subsequent to the inquest Worthing Homes provided further information to assist with the preparation of this report. This confirmed that RedAssure no longer existed and that Worthing Homes, as a social housing provider, were not involved in providing care or medical assistance. They state that medical information gathered at the application stage is solely for the purpose of ascertaining the prospective resident’s suitability for a property.
Worthing Homes provided a full version of a review record from 2015 clearly stating that Mr Wells had learning difficulties. In addition a GP letter provided to Worthing Homes in 2008 states that Mr Wells had a low IQ. Neither of these pieces of information were transferred on the front sheet of the record , which appears to have been the source of the information entered onto Carenet.
As a result of the incomplete records and summary Appello & SECAMB were not provided with important and accurate information regarding Mr Wells.
” Source location John Michael WELLS · Prevention of Future Deaths report
Open source report
7 Mar 2018 Mrs Elizabeth Marion Griffin · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 7
Failure to make linked fire alarms a contractual requirement for telecare clients View source Failure to escalate fire-alarm activations to the fire brigade within 30 seconds View source Failure to visibly flag unlinked fire alarms in client records View source
Failure to identify and replace unlinked fire alarms in a timely and auditable manner View source Inadequate staff training on standards-compliant fire-alarm response View source Failure to train staff to recognise and escalate linked and unlinked fire-alarm sounds View source Failure of telecare systems to maintain communication throughout clients' properties View source See 4 more concerns
This report raised 6 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
Mrs Elizabeth Marion Griffin · 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
Mrs Elizabeth Marion Griffin, who was wheelchair bound due to advanced multiple sclerosis, was alone at home in bed when a dishwasher fire started on 14 July 2017. She activated her pendant alarm, but the responder did not recognise the smoke alarm, could not communicate effectively with her, and did not call the fire brigade; Mrs Griffin later died in hospital on 21 August 2017 from smoke inhalation injuries and bronchopneumonia. The concerns included delayed action by the dishwasher manufacturer, lack of appliance-owner registration and contact, and shortcomings in telecare arrangements, including unlinked fire alarms, responder training, communication, and escalation procedures.
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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 make linked fire alarms a contractual requirement for telecare clients
Wider context from the report “8. That telecare systems providers and WWA in particular, insist that their clients, who by definition are vulnerable, have linked fire alarms as a contractual requirement for both new and existing clients in the same way that such providers insist on the provision to them by the client of keys to the clients’ homes.
” Source location Mrs Elizabeth Marion Griffin · Prevention of Future Deaths report
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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 escalate fire-alarm activations to the fire brigade within 30 seconds
Wider context from the report “7. That telecare system operators and WWA in particular, apply the British Standards Institute requirement to call for the help of the fire brigade after 30 seconds maximum of trying to contact a client if the client’s fire alarm goes off .
” Source location Mrs Elizabeth Marion Griffin · Prevention of Future Deaths report
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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 visibly flag unlinked fire alarms in client records
Wider context from the report “12. That telecare systems providers and WWA in particular, highlight on the front screen of the client details, if that client has an unlinked fire alarm , until such a time as the unlinked alarm is replaced by a linked one, so as to alert call responders that sounds heard in the back ground or call may represent an activated fire alarm and thus the fire brigade may need to be called to the client’s home by the call responder.
” Source location Mrs Elizabeth Marion Griffin · 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 Failure to identify and replace unlinked fire alarms in a timely and auditable manner
Wider context from the report “9. That telecare systems providers and WWA in particular, take active steps to identify clients without linked fire alarms and arrange for them to be replaced with linked fire alarms and that this should be done in a timely and auditable fashion .
” Source location Mrs Elizabeth Marion Griffin · Prevention of Future Deaths report
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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 Inadequate staff training on standards-compliant fire-alarm response
Wider context from the report “10. That telecare systems providers and WWA in particular, train their staff on the appropriate response to the activation of a fire alarm and that this should be according to the standards laid down by the British Standards Institute .
” Source location Mrs Elizabeth Marion Griffin · Prevention of Future Deaths report
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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 train staff to recognise and escalate linked and unlinked fire-alarm sounds
Wider context from the report “11. That telecare systems providers and WWA in particular, train their staff as to what fire alarm activation sounds like whether from a linked or unlinked alarm and that they should call the fire brigade appropriately if they are heard by the responder to be activated .
” Source location Mrs Elizabeth Marion Griffin · Prevention of Future Deaths report
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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 telecare systems to maintain communication throughout clients' properties
Wider context from the report “6. That telecare systems be organised such that a client operating a pendant alarm can talk with the responder no matter where the client is within their property such as to allow a client with mobility problems to be in proper communication with their telecare system operator at all times .
” Source location Mrs Elizabeth Marion Griffin · Prevention of Future Deaths report
Open source report
21 Sep 2017 Derek Clifford Dudley · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6
Failure to require trainee Telecare Operators to obtain approval before closing calls View source Failure to persist in offering and persuading service users to accept help after alarm activation View source Failure to take further action when follow-up contact after an unanswered alarm call fails View source
Lack of pro forma questions for assessing needs after alarm activation View source Allowing trainee Telecare Operators to take calls without direct supervision View source Failure to keep alarm calls open until service users are safely recovered from falls View source See 3 more concerns
This report raised 2 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
Derek Clifford Dudley · 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 Clifford Dudley was found deceased from hypothermia outside the back door of his home on 6 March 2017, after previously activating his community alarm following a fall. Concerns included the call being ended before he had got up, limited follow-up after a later unanswered call, unsupervised trainee operators, the absence of pro forma questions, and insufficient background information for assessing service users’ needs.
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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 require trainee Telecare Operators to obtain approval before closing calls
Wider context from the report “The Telecare operator who took Mr Dudley’s call was in her probationary period with the Service but was able to take the call without direct supervision and did not need to seek approval before closing the call .
” Source location Derek Clifford Dudley · 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 Failure to persist in offering and persuading service users to accept help after alarm activation
Wider context from the report “Mr Dudley was only offered an ambulance once during the course of the telephone conversation and no attempt was made to persuade him to accept any help.
” Source location Derek Clifford Dudley · 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 Failure to take further action when follow-up contact after an unanswered alarm call fails
Wider context from the report “The operator attempted to contact Mr Dudley by telephone again 1.5 hours later , which ████████ again stated was in breach of Telecare’s policy, but there was no answer and no further action was taken.
” Source location Derek Clifford Dudley · 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 Lack of pro forma questions for assessing needs after alarm activation
Wider context from the report “Evidence was heard during the inquest that no pro forma questions are provided to the Telecare operators for dealing with calls and call handling guidance is provided to each operator on a USB stick which they can access via their work computer if needed.
” Source location Derek Clifford Dudley · 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 Allowing trainee Telecare Operators to take calls without direct supervision
Wider context from the report “The Telecare operator who took Mr Dudley’s call was in her probationary period with the Service but was able to take the call without direct supervision and did not need to seek approval before closing the call.
” Source location Derek Clifford Dudley · 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 Failure to keep alarm calls open until service users are safely recovered from falls
Wider context from the report “The call was terminated without Mr Dudley having got up from his fall , which ████████ confirmed was in breach of the policy of CSS Telecare Service .
” Source location Derek Clifford Dudley · Prevention of Future Deaths report
Open source report
3 May 2017 Beryl Varcoe · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Failure to thoroughly range-test alarms throughout service-users’ homes View source
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
Beryl Varcoe · 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
Beryl Varcoe fell or collapsed in her bedroom and repeatedly pressed her community alarm pendant, but the alarm did not activate because her bedroom was outside the base unit’s radio range. She remained on the floor until the following day, developed pneumonia and chest sepsis, and died in hospital on 21 April 2016. The principal concern was that alarms installed or upgraded without thorough range testing may not function throughout clients’ homes, potentially placing other service users at risk.
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 thoroughly range-test alarms throughout service-users’ homes
Wider context from the report “The court heard evidence from ████████, the head of Elmbridge Borough Council’s Community Alarms Service, who told the court that the service has 1,700 clients and two installation officers, who are responsible for fitting and upgrading alarms in clients’ homes.
████████ told the court that it was his expectation that the installation officers carried out thorough range testing when fitting and upgrading alarms, to check that the pendant was capable of activating the base unit from all internal and external parts of a property.
The court also heard evidence from the particular installer who fitted and upgraded Mrs Varcoe’s alarm. He gave inconsistent evidence with regards to his practises in respect of range testing. However, having considered the entirety of his evidence, the court is concerned that it was his practice only to range test pendants in those parts of the service user’s home, which they used most regularly and in which they felt most vulnerable .
The court was told that the installation officer who fitted Mrs Varcoe’s alarm has now retired. The court was also told that the Community Alarms Service has developed a number of new procedures, which are to be introduced imminently, with the aim of ensuring that thorough range testing is documented at the time of each alarm installation or upgrade.
However, the court is concerned that a significant number of the service’s clients currently have alarms, which were fitted prior to the introduction of the new procedures and by the same installation officer who fitted Mrs Varcoe’s alarm. As such there is a risk that those service-users may have alarms which do not function throughout the entirety of their homes .
Elmbridge Borough Council’s Community Alarms Service has a significant number of clients who currently have alarms, which may not have not been thoroughly range-tested and may not function throughout the entirety of the service-users’ homes .
” Source location Beryl Varcoe · Prevention of Future Deaths report
Open source report
24 Oct 2014 Hilda May Cole · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 1
Failure to inform service users about additional alarm facilities View source
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
Hilda May Cole · 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
Hilda May Cole, aged 86, was found dead at home on 7 July 2014 after dying from burns, probably caused by a lit cigarette dropped onto a sofa or material on it. The concern was that her pendant alarm system could have been linked to a fire alarm, but her family were unaware of this facility and had not subscribed to it; the report questioned whether existing and new customers were adequately informed.
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 inform service users about additional alarm facilities
Wider context from the report “1. Mrs Cole had one of the pendant alarms supplied by you. She was a smoker with reduced mobility and there was a risk of fires. At the inquest I heard that family members were not aware that the system that you provide can be linked into other alarms such as fire alarms and burglar alarms . If they had been aware they would have subscribed to the fire alarm system for Mrs Cole. The family have told me that they have subsequently seen literature on which these others services do appear. However they wonder if you should be taking more steps to advise existing service users of the additional facilities you provide and if new customers are aware of these facilities . I wonder if this something that you should be pursuing?
” Source location Hilda May Cole · Prevention of Future Deaths report
Open source report
Concerns raised 2
Lack of interim protection for Telecare package users pending interlink installation View source Lack of standard interlink connection for smoke alarms on the Conwy County Telecare package View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Alfred Leonard Hodges · 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
Alfred Leonard Hodges, who had severe mobility, frailty and hearing difficulties, died aged 97 after a fire at his home on 26 June 2013. The report raised concerns that his smoke alarm was not interlinked with his Telecare system, that interim protections were unclear, and that he had not received a free Fire Home Safety Check. The inquest concluded that the medical cause of death was carbon monoxide poisoning and severe ischaemic heart disease.
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 interim protection for Telecare package users pending interlink installation
Wider context from the report “(2) It is understood that there is a 2 year roll out programme to provide interlink as standard for those on a Conwy Council Telecare package. I am concerned as to what interim provisions are in place to protect those on the Telecare package until interlink is installed
” Source location Alfred Leonard Hodges · 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 Lack of standard interlink connection for smoke alarms on the Conwy County Telecare package
Wider context from the report “(1) Individuals on the Telecare package in Conwy County do not have a standard a provision that their smoke alarm is connected via interlink although this is seen as necessary in all other North Wales Counties due to the vulnerability of those on the scheme.
” Source location Alfred Leonard Hodges · 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 Establish a six-month full-time Council post to accelerate installation of linked smoke detectors for Telecare clients.
Verbatim wording from the response “Officers from NWFRS and Conwy County Borough Council met again on 11th December 2013 and reached an agreement for the funding of a full time post in the Council for 6 months in order to install the linked smoke alarms in a considerably shorter timescale. The NWFRS also agreed to provide 500 smoke alarms during 2014/15 and have provided refresher training for Conwy Telecare Services installers on the correct positioning of smoke detectors in domestic dwellings and, will be providing fire safety awareness training for social services staff. Between December and February 105 detectors have been installed and the new full time officer has now started work.” Source location 2014-0033-Response-by-Conway
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 Install linked smoke detectors for Telecare clients identified as lacking them, using the accelerated installation programme.
Verbatim wording from the response “The Council and NWFRS reviewed the current practice in October 2013. The NWFRS concluded that it would be beneficial for people in Conwy if a linked smoke detector was installed as part of the basic Telecare package on initial installation, or during regular support visits to those already with a Telecare package. The NWFRS donated 900 linked smoke detectors to the Council for the Conwy Telecare Service to install for clients identified as not having a linked detector.” Source location 2014-0033-Response-by-Conway
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 Review current Council and Fire Service practice for providing linked smoke detectors with Telecare.
Verbatim wording from the response “The Council and NWFRS reviewed the current practice in October 2013. The NWFRS concluded that it would be beneficial for people in Conwy if a linked smoke detector was installed as part of the basic Telecare package on initial installation, or during regular support visits to those already with a Telecare package. The NWFRS donated 900 linked smoke detectors to the Council for the Conwy Telecare Service to install for clients identified as not having a linked detector.” Source location 2014-0033-Response-by-Conway
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.