6 Feb 2018 MAVIS JEANNE REVES · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 5 Failure to clearly label keys in the key safe View source Delays in analogue Careline connection View source Failure of the analogue Careline system to support concurrent emergency access and calls View source Failure to ensure emergency services can gain building access without undue delay View source Failure to ensure residents know the limitations of the Careline system View source See 2 more concerns
Responses linked to these concerns
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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.
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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 FirstPort Retirement Property Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly label keys in the key safe
Wider context from the report “(3) The key safe contains numerous keys including the master key. The paramedic had difficulties identifying which was the master key .
It is important that the keys be clearly labelled to avoid delay in the emergency services gaining access.
” 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 FirstPort Retirement Property Services Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in analogue Careline connection
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 .
” 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 FirstPort Retirement Property Services Limited; that does not assign responsibility.
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.
” 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 FirstPort Retirement Property Services Limited; that does not assign responsibility.
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.
” 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 FirstPort Retirement Property Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure residents know the limitations of the Careline system
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.
” 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 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
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 Inform residents about Careline entry methods and analogue-system limitations through a meeting and written follow-up.
Verbatim wording from the response “2.3.1 To ensure that the residents are fully aware of how the current Careline System works we held a residents meeting on 4 April 2018. The findings contained within the Prevention of Future Deaths report were discussed with the residents as well as the possibility of a new digital entry system. The contents of the meeting was followed up in writing, the letter was provided to the residents on 10 April 2018. Within the letter the residents were advised that a further meeting would take place on 2 May 2018 should they wish to ask any further questions or raise any concerns regarding the entry system.” Source location 2018-0035-Response-by-FirstPort-Retirement
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 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
Open published response
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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 existing analogue entry system is industry-accepted, fit for purpose, and residents do not wish to replace it with a digital system.
Verbatim wording from the response “2.2.1 The LD3 analogue system currently in place was installed in September 2014 at a cost of £24,958.00. The system is an industry-accepted grade and recognised as fit for purpose. Others within the industry regularly install the system in newly constructed/refurbished residential facilities similar to the premises in question.” Source location 2018-0035-Response-by-FirstPort-Retirement
Open published response
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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 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
Open published response
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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 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations