17 Oct 2025 MELANIE JAYNE WALKER · Prevention of Future Deaths report Manchester West
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Concerns raised 3 Failure to ensure staff awareness and training about current heart-monitor deficiencies View source Failure of heart monitors to alert clinicians to cardiac events View source Failure of heart monitors to re-alert when ECG leads remain disconnected View source
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MELANIE JAYNE WALKER · 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
Melanie Jayne Walker, who had a complex medical history and drug and alcohol dependency, was found collapsed and partially responsive on 17 December 2024 and later suffered an unobserved cardiac arrest in hospital. She sustained an irreversible hypoxic brain injury and died on 26 December 2024 after life support was withdrawn. The principal concern was that her heart monitor did not alert staff to the cardiac event, partly because monitoring equipment had become disconnected and the monitor’s alert system did not re-alarm after acknowledgement, creating an ongoing patient-safety risk.
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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 Philips Electronics UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff awareness and training about current heart-monitor deficiencies
Wider context from the report “1. Whilst the deceased had been fitted with a heart monitor whilst being assessed in the busy Resuscitation Department of the hospital, she experienced a cardiac event that ought to have triggered her hearty monitor to alert clinicians to this medical emergency, in fact, this did not occur.
2. A Patient Safety Incident Investigation (PSII) had been commissioned by the Hospital Trust determined:
a. Where, an untoward event – such as an abnormal reading, or (as in this case) with a monitor lead was inadvertently disconnected, this creates a blue ‘in op’ alert with a ‘bloop’ type sound (as opposed to a continuous alarm) – with the consequence that the ECG lead is unable to detect a reading and is therefore inoperable.
b. The ‘in op’ alert creates a blue banner to alert staff. Once acknowledged (by the staff member pressing the button) this does not re-alert, even if the lead remains disconnected,
c. Accordingly, there is a risk that a lead could remain disconnected, if the reason for the staff pressing ‘acknowledge’ is to acknowledge an abnormal reading.
d. Whilst Royal Bolton Hospital Trust have mitigated the identified patient safety issues and it understood that the manufacturers (Philips) are undertaking to reconfigure their monitors so that when an ECG lead is removed this creates a ‘yellow alert’ that will ensure that the monitor will re-alarm in the scenario of a patient removing the lead when unobserved – the evidence established that this risk remains an issue for other hospital trusts in the interim.
e. Royal Bolton Hospital have identified the need for patients who are deliberately or inadvertently removing monitoring equipment will be the subject of additional support, such as a 1:1 Health Care Assistant.
3. There remains an ongoing concern that until these heart monitoring machines are re-configured, and staff made aware and trained as to their current deficiencies , with no mitigating arrangements in place , that a patient can suffer a fatal cardiac event in any clinical setting and an erroneous assumption made by health care staff that a patient is being appropriately monitored .
” 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 Philips Electronics UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of heart monitors to alert clinicians to cardiac events
Wider context from the report “1. Whilst the deceased had been fitted with a heart monitor whilst being assessed in the busy Resuscitation Department of the hospital, she experienced a cardiac event that ought to have triggered her hearty monitor to alert clinicians to this medical emergency, in fact, this did not occur .
2. A Patient Safety Incident Investigation (PSII) had been commissioned by the Hospital Trust determined:
a. Where, an untoward event – such as an abnormal reading, or (as in this case) with a monitor lead was inadvertently disconnected, this creates a blue ‘in op’ alert with a ‘bloop’ type sound (as opposed to a continuous alarm) – with the consequence that the ECG lead is unable to detect a reading and is therefore inoperable.
b. The ‘in op’ alert creates a blue banner to alert staff. Once acknowledged (by the staff member pressing the button) this does not re-alert, even if the lead remains disconnected,
c. Accordingly, there is a risk that a lead could remain disconnected, if the reason for the staff pressing ‘acknowledge’ is to acknowledge an abnormal reading.
d. Whilst Royal Bolton Hospital Trust have mitigated the identified patient safety issues and it understood that the manufacturers (Philips) are undertaking to reconfigure their monitors so that when an ECG lead is removed this creates a ‘yellow alert’ that will ensure that the monitor will re-alarm in the scenario of a patient removing the lead when unobserved – the evidence established that this risk remains an issue for other hospital trusts in the interim.
e. Royal Bolton Hospital have identified the need for patients who are deliberately or inadvertently removing monitoring equipment will be the subject of additional support, such as a 1:1 Health Care Assistant.
3. There remains an ongoing concern that until these heart monitoring machines are re-configured, and staff made aware and trained as to their current deficiencies, with no mitigating arrangements in place, that a patient can suffer a fatal cardiac event in any clinical setting and an erroneous assumption made by health care staff that a patient is being appropriately monitored.
” 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 Philips Electronics UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of heart monitors to re-alert when ECG leads remain disconnected
Wider context from the report “1. Whilst the deceased had been fitted with a heart monitor whilst being assessed in the busy Resuscitation Department of the hospital, she experienced a cardiac event that ought to have triggered her hearty monitor to alert clinicians to this medical emergency, in fact, this did not occur.
2. A Patient Safety Incident Investigation (PSII) had been commissioned by the Hospital Trust determined:
a. Where, an untoward event – such as an abnormal reading, or (as in this case) with a monitor lead was inadvertently disconnected, this creates a blue ‘in op’ alert with a ‘bloop’ type sound (as opposed to a continuous alarm) – with the consequence that the ECG lead is unable to detect a reading and is therefore inoperable.
b. The ‘in op’ alert creates a blue banner to alert staff. Once acknowledged (by the staff member pressing the button) this does not re-alert, even if the lead remains disconnected ,
c. Accordingly, there is a risk that a lead could remain disconnected , if the reason for the staff pressing ‘acknowledge’ is to acknowledge an abnormal reading.
d. Whilst Royal Bolton Hospital Trust have mitigated the identified patient safety issues and it understood that the manufacturers (Philips) are undertaking to reconfigure their monitors so that when an ECG lead is removed this creates a ‘yellow alert’ that will ensure that the monitor will re-alarm in the scenario of a patient removing the lead when unobserved – the evidence established that this risk remains an issue for other hospital trusts in the interim .
e. Royal Bolton Hospital have identified the need for patients who are deliberately or inadvertently removing monitoring equipment will be the subject of additional support, such as a 1:1 Health Care Assistant.
3. There remains an ongoing concern that until these heart monitoring machines are re-configured, and staff made aware and trained as to their current deficiencies, with no mitigating arrangements in place, that a patient can suffer a fatal cardiac event in any clinical setting and an erroneous assumption made by health care staff that a patient is being appropriately monitored.
” Open source report
27 Aug 2021 Ann GERAGHTY · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Failure of cardiac monitoring alarms to remain active for certain abnormal heart rhythms View source
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Ann GERAGHTY · 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
Ann GERAGHTY was admitted to Good Hope Hospital with heart failure and later suffered a cardiac arrest before dying on 30 March 2021 from multiorgan failure associated with congestive cardiac failure and dilated cardiomyopathy. Two periods of ventricular standstill recorded by cardiac telemetry were missed, and concerns were raised that the monitoring system’s self-terminating alarms could pose a risk of future deaths unless addressed.
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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 Philips Electronics UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of cardiac monitoring alarms to remain active for certain abnormal heart rhythms
Wider context from the report “3. Medical engineers were asked to analyse the telemetry and noted that on 8 March the monitor's alarm had triggered and that it was a self-terminating alarm as the heart rhythm had corrected itself . There was no evidence that staff muted the alarm or that there was any fault with the equipment. Thus, this self-correcting function is an intended function of the monitor .
4. Following the Trust's internal investigations, it was recommended that discussion with the manufacturers of the cardiac monitoring equipment take place to establish whether the alarms can be configured in such a way that the alarm does not self-terminate when certain abnormal heart rhythms correct themselves . The evidence was that this discussion took place on 31 July 2021, but that there has been no progress since that time , with the responsibility now lying with the manufacturer (i.e. yourselves) to develop a software update or alternative system to ensure that the issue of self-terminating alarms is remedied.
5. At inquest, it could not be determined whether Phillips central monitoring stations (model number M3151) are utilised by other Trusts nationally, but given that Philips is one of the largest providers of cardiac monitoring equipment to the NHS, it is presumed that this monitoring station is deployed in other Trusts nationally.
6. I therefore have concerns that, unless immediate consideration is given to this issue by the manufacture (i.e. yourselves), there is a risk of future deaths occurring - both within the Trust and nationally within other Trusts - and will continue to exist in the future until such time as this is addressed .
” 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 Investigated the reported alarm incident through telemetry review, configuration assessment, and on-site simulation testing.
Verbatim wording from the response “Strip Review
As the Device Manufacturer, Philips’ first contact from the Hospital in regard to this incident was on June 29, 2021. This was an informal request to investigate to a Philips Clinical Application Specialist (CAS) whilst visiting Heartlands Hospital on another matter. The question from the Matron was whether a Ventricular Standstill would cause an alarm and, if so, how long it would last. A general ECG waveform strip and an Asystole Alarm strip, printed out around the time of the incident, was emailed to the CAS on July 18, 2021. The Asystole Alarm strip showed this alarm generated at the time of the Ventricular Standstill, but without the Clinical Audit Logs, the duration of this alarm and any other actions taken around the time of this alarm are unknown.” Source location 2021-0288-Response-from-Philips-Healthcare_Published
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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 telemetry system does not self-terminate red alarms and was operating as designed.
Verbatim wording from the response “Self-Terminating Alarms
Per the report, hospital Medical Engineers were asked to review the Telemetry and the hospital Medical Engineers noted that on March 8, 2021, the monitors alarm had triggered and that it was a self-terminating alarm. Philips is interpreting this description as the alarm stopped on its own accord without user interaction. Any ventricular standstill of 4-10 seconds of duration would meet the definition of Asystole which is a red arrhythmia alarm. There is not a configuration to change Asystole or any other red arrhythmia alarm to self-terminate for a Telemetry / Central Station setup. In summary, the product is not designed to self-terminate red alarms nor is Philips able to reproduce the described behavior.” Source location 2021-0288-Response-from-Philips-Healthcare_Published
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17 Mar 2016 Jacqueline Emma Brown Scott · Prevention of Future Deaths report Inner West London
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Concerns raised 7 Failure of the BIPAP display to keep the battery-power indicator visible during multiple alarms View source Lack of an isolated power supply for ward beds routinely using life-saving equipment View source Failure to train BIPAP staff to recognise battery-power indicators and battery-depletion alarms View source Failure to repair emergency call bells after notification of a fault View source Lack of a system or check to alert ward staff to local mains-power failure View source Failure of the BIPAP alarm system to provide a distinct urgent warning for battery depletion View source Conflict between electrical-safety guidance for clinical risk areas View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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.
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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 Philips Electronics UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the BIPAP display to keep the battery-power indicator visible during multiple alarms
Wider context from the report “(i)The BIPAP Trilogy 202 machine had a subtle visual display symbol which denoted when the machine was running on battery power. That symbol is not visible if there are many alert alarms as the alarm messages fill up the screen as they come in pushing the earlier alerts (including low battery) off the screen. In Mrs Scott’s case there had been 17 alert alarms in the space of 50 minutes.
” 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 Philips Electronics UK Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of an isolated power supply for ward beds routinely using life-saving equipment
Wider context from the report “(iv) Richmond ward ADU beds was designated as a category 4 area which in this case meant there was no isolated power supply (IPS) provided to the ward notwithstanding life-saving equipment was routinely used .
” 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 Philips Electronics UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to train BIPAP staff to recognise battery-power indicators and battery-depletion alarms
Wider context from the report “(iii) Staff who were experienced and trained on the BIPAP machine did not appear to be trained to be alert to the situation or to the significance of a battery symbol showing on the machine when the machine was plugged in to the mains or to any particular alarm which denoted battery depletion rather than mask slippage .
” 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 Philips Electronics UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to repair emergency call bells after notification of a fault
Wider context from the report “(vii) The crash bell for bed bay 5 did not work when the emergency arose . However estates management had been notified some days earlier of the broken patient call in the same bay . This was of concern as both emergency bells were on the same circuit and not fixed until 2 April 2014 when by chance the failure of electricity was identified.
” 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 Philips Electronics UK Limited; that does not assign responsibility.
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.
” 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 Philips Electronics UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the BIPAP alarm system to provide a distinct urgent warning for battery depletion
Wider context from the report “(ii)The BIPAP Trilogy 202 machine has the same alarm sound for battery depletion as for circuit disconnect (where for example the face mask slipped) which was the more usual and expected reason for an alarm and these two factors separately and together did not have any feature of urgent warning to alert staff to battery depletion .
” 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 Philips Electronics UK Limited; that does not assign responsibility.
PFD Monitor interpretation Conflict between electrical-safety guidance for clinical risk areas
Wider context from the report “(v) Hospital Technical Memoranda (HTM) 06-01 Part A provides advice and guidance and a benchmark standard for electrical installation, maintenance and safety etc in healthcare premises. It is a matter of concern that there is a conflict of advice between clause 4.22 and Clause 6.62 . Clause 4.22 states: “Clinical treatment and patient safety may be compromised ( but not endangered) by any interruption of electrical supply “ whereas Clause 6.62 states: “In clinical risk Category 4 and 5 areas the patient environment should have at least two IPS circuits at the bedhead”
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations