26 Nov 2024 Elan Gransford Adams · Prevention of Future Deaths report East London
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Concerns raised 3 Failure to provide a reliable resident call bell system that staff can hear and respond to View source Failure of qualified nursing staff to provide clear and complete clinical information to emergency controllers View source Failure to provide reliable phone connections for emergency calls from residents’ bedrooms View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Use updated manager walk-round checks, half-hourly resident checks, and ad-hoc call-bell tests to verify call-bell availability and operation.
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Action
Upgrade the entire Manor Farm nurse call system.
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Action
Disseminate the Coroner’s concerns and updated Emergency Protocol to all services, and require managers to check emergency equipment and communication systems.
View source
Action
Enable staff to make 999 calls directly from Care Vision handsets via the Home’s Wi-Fi.
View source
Action
Replace Wi-Fi hotspots, test post-installation signal coverage, and add further hotspots where weak areas remain.
View source
Action
Deliver choking, dysphagia, emergency-call, deterioration-recognition, handover, incident-reporting, and professional-accountability training to Manor Farm staff.
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Action
Train all new staff during induction on the updated Call Bell Policy and monitor compliance.
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Action
Apply the updated Call Bell Policy, including urgent reporting, repair or replacement, risk assessment, and Regional Director approval when failures cannot be immediately repaired.
View source
Action
Update the Emergency Ambulance Protocol to require structured clinical checks, clear communication, positive listening, and use of available 999 calling equipment.
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Action
Replace telephones and install additional cordless and landline phones to strengthen communication coverage.
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AI-generated summary
Elan Gransford Adams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Elan Gransford Adams, a nursing home resident, choked on a burger on 5 February 2024 and died at hospital later that evening. The substantive concerns included poor-quality emergency-call communication, unclear clinical information provided to the ambulance controller, and a faulty resident call bell with limited assurance that staff could hear it during busy periods.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Abbey Healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a reliable resident call bell system that staff can hear and respond to
Wider context from the report “(3) The resident call bell had been faulty for an extended period of time . Whilst a handheld bell was provided, there was little assurance that staff could hear this during busy periods , such as during mealtimes. The family had been present on a prior occasion when the temporary bell had been rung and no staff attended .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Abbey Healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure of qualified nursing staff to provide clear and complete clinical information to emergency controllers
Wider context from the report “(2) The qualified nursing staff were concerningly unclear in the substance of communication with the emergency controller . They were unable to clearly answer the question about breathing status . They did not provide key clinical information to the controller , such as the much-reduced oxygen saturation reading.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Abbey Healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to provide reliable phone connections for emergency calls from residents’ bedrooms
Wider context from the report “(1) The call to the London Ambulance Service was of very poor quality partly due to interference in the phone line connection . The inquest heard that the staff had problems with the phone quality “most of the time” and continue to have difficulties when making emergency calls from resident’s bedrooms .
” 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 Use updated manager walk-round checks, half-hourly resident checks, and ad-hoc call-bell tests to verify call-bell availability and operation.
Verbatim wording from the response “Our Manager Daily Walk Round Checklist has been updated (Appendix 5). Where spot checks of residents rooms are completed, it is now part of the check to ascertain if ‘all calls are within reach and operational’. This includes a:” Source location Response from Abbey Healthcare
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 Upgrade the entire Manor Farm nurse call system.
Verbatim wording from the response “Following the Inquest and a request for feedback from all services within Abbey Healthcare, intermittent faults were identified with the call bell systems at Manor Farm. This was in keeping with our immediate checks following the Inquest. There were no call bell issues identified elsewhere.” Source location Response from Abbey Healthcare
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 Disseminate the Coroner’s concerns and updated Emergency Protocol to all services, and require managers to check emergency equipment and communication systems.
Verbatim wording from the response “To ensure that as a company, we have implemented change across all our sites, on 5 December 2024 we contacted each service to make them aware of the Coroner’s concerns following the Inquest in this matter. A copy of the Coroner’s Regulation 28 was provided to all managers. The Emergency Protocol, which was updated in November 2024, was circulated simultaneously. We asked all Home Managers to check the following in their service:” Source location Response from Abbey Healthcare
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 Enable staff to make 999 calls directly from Care Vision handsets via the Home’s Wi-Fi.
Verbatim wording from the response “The handsets, which have our electronic care system installed (Care Vision), now have a separate app installed. This allows staff to call 999 directly from the handset. Staff are now reliant on mobile phone signal as calls are made directly via the Home’s Wi-Fi.” Source location Response from Abbey Healthcare
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 Replace Wi-Fi hotspots, test post-installation signal coverage, and add further hotspots where weak areas remain.
Verbatim wording from the response “The Wi-Fi hotspots are in the process of being replaced and will be installed by 1st February 2025. Tests will be conducted following this, specifically to check for any signal issues post-installation. If any weak areas of signal are identified, further Wi-Fi hotspots will be installed, to boost the signal throughout the Home.” Source location Response from Abbey Healthcare
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 Deliver choking, dysphagia, emergency-call, deterioration-recognition, handover, incident-reporting, and professional-accountability training to Manor Farm staff.
Verbatim wording from the response “b) Choking and dysphagia training has been completed on 9 and 13 January 2025. This not only covered the awareness of the need to discuss cases of silent choking and how to deal with a 999 call, but also included a simulation of a 999 call and how it should be handled to ensure effective communication between emergency services and staff at all times.” Source location Response from Abbey Healthcare
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 Train all new staff during induction on the updated Call Bell Policy and monitor compliance.
Verbatim wording from the response “All staff, as part of their induction, will receive training on this policy. Compliance with this policy will be monitored and any non-compliance may result in disciplinary action.” Source location Response from Abbey Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Apply the updated Call Bell Policy, including urgent reporting, repair or replacement, risk assessment, and Regional Director approval when failures cannot be immediately repaired.
Verbatim wording from the response “Half hourly checks are also conducted on residents, and ad-hoc tests of their call bells are undertaken. Where call bell failures are identified, staff are expected to follow the procedure as set out in our updated Call Bell Policy (Appendix 6). The policy, updated in November 2024, makes clear that in the event of a call bell failure, the following steps should be taken:” Source location Response from Abbey Healthcare
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 Update the Emergency Ambulance Protocol to require structured clinical checks, clear communication, positive listening, and use of available 999 calling equipment.
Verbatim wording from the response “In November 2024, we reviewed and updated our Emergency Ambulance Protocol (Appendix 2). This was prior to the further update to this policy, as seen at Appendix 1. This details that, where 999 are to be called, staff members need to have completed the following checks/be able to relay the following information to the call handler:” Source location Response from Abbey Healthcare
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 Replace telephones and install additional cordless and landline phones to strengthen communication coverage.
Verbatim wording from the response “a) All telephones are being replaced;” Source location Response from Abbey Healthcare
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations