18 Sep 2024 Ali Mohammed Nazemi · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 2 Failure to prevent or detect unintentional triggering of the uncontrolled movement device View source Unavailability of a means to reset the uncontrolled movement device or obtain effective assistance after activation 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. 1
Action
Provide passenger-release instructions in the lift control panel for attending engineers and emergency services.
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AI-generated summary
Ali Mohammed Nazemi · 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
Ali Mohammed Nazemi died from natural causes at Pinderfields Hospital on 18 January 2024 after an acute stroke and aspiration. His transfer from home was delayed when he and paramedics became trapped in a lift, raising concern that the lift’s uncontrolled movement device could be unintentionally activated without a way to reset it, leaving people dependent on Fire & Rescue Service rescue.
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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 Schindler Ltd.; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent or detect unintentional triggering of the uncontrolled movement device
Wider context from the report “The lift that trapped Mr Nazemi and the attending paramedics is identified in an e-Worksheet generated by Schindler (copy attached) as a 20049625 MOD Replacement 6300.
The lift was examined by Schindler on the day of the incident, and it was found that “the uncontrolled movement device had been activated by persons using the lift”. The lift was being used by four paramedics who were transporting Mr Nazemi in a carry chair, the lift being too small to accommodate a stretcher. None of the paramedics were aware of having activated the uncontrolled movement device.
The evidence suggested that that was no way to reset the uncontrolled movement device once it had been activated, and that a call to the 24/7 helpline displayed in the lift could not help. Ultimately those trapped within the lift had to wait for the Fire & Rescue Service to break the lift door down.
Although Mr Nazemi was so ill that the 45 minute delay caused by the activation of the uncontrolled movement device made no difference to his outcome, there is a concern that others in his position may be seriously affected by the unintentional (and unnoticed) triggering of the uncontrolled movement device and by the fact that nothing apparently can be done to reverse any such unintentional triggering, such that those affected have to await rescue by the Fire & Rescue Service.
” 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 Schindler Ltd.; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a means to reset the uncontrolled movement device or obtain effective assistance after activation
Wider context from the report “The lift that trapped Mr Nazemi and the attending paramedics is identified in an e-Worksheet generated by Schindler (copy attached) as a 20049625 MOD Replacement 6300.
The lift was examined by Schindler on the day of the incident, and it was found that “the uncontrolled movement device had been activated by persons using the lift”. The lift was being used by four paramedics who were transporting Mr Nazemi in a carry chair, the lift being too small to accommodate a stretcher. None of the paramedics were aware of having activated the uncontrolled movement device.
The evidence suggested that that was no way to reset the uncontrolled movement device once it had been activated , and that a call to the 24/7 helpline displayed in the lift could not help . Ultimately those trapped within the lift had to wait for the Fire & Rescue Service to break the lift door down.
Although Mr Nazemi was so ill that the 45 minute delay caused by the activation of the uncontrolled movement device made no difference to his outcome, there is a concern that others in his position may be seriously affected by the unintentional (and unnoticed) triggering of the uncontrolled movement device and by the fact that nothing apparently can be done to reverse any such unintentional triggering, such that those affected have to await rescue by the Fire & Rescue Service .
” 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 Provide passenger-release instructions in the lift control panel for attending engineers and emergency services.
Verbatim wording from the response “In accordance with clause 5.10.1 of BS72-55, Schindler provided instructions for the release of passengers in the control panel of the lift. This is available to the engineers attending call outs and the fire service who attend in case of emergency.” Source location Response from Schindler Ltd
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 Existing trained-personnel procedures and passenger-release instructions in the lift control panel are considered sufficient for releasing trapped passengers.
Verbatim wording from the response “Schindler are compliant with this clause. The process for when there is an entrapment is that a call is raised to the Schindler call centre who then contacts a nearby Schindler Engineer to attend a call out and release the entrapped passenger. All Schindler Engineers who attend call outs are trained and authorised. The recommended procedures should be followed for the release of passengers, and it is preferable for trained lift industry personnel to release trapped passengers as opposed to lay people. The reasoning behind this is that if any lay person could open the lift, the risk of death increases substantially.” Source location Response from Schindler Ltd
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 No further action is considered necessary because the lift conforms to and operates as expected under applicable safety standards and regulations.
Verbatim wording from the response “We therefore propose that no further action be taken as the lift fully conforms and operates as expected in accordance with EN81-20, BS72-55 and the Lift Regulations 2009. In addition, full passenger release information is available to the emergency services within the control panel of the lift. It is duly given that any persons performing passenger release should familiarise themselves with the process.” Source location Response from Schindler Ltd
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 Passengers cannot activate UCMP; it is an automatic control-panel function that operated as required when detecting the door-contact safety fault.
Verbatim wording from the response “We believe there has been a misunderstanding of what is meant by the UCMP being activated by the passengers. The passengers cannot activate the UCMP, the UCMP is purely a processor monitoring function embedded within the architecture of the lift control panel. The lift control panel is normally situated on the top floor landing adjacent to the lift entrance. The UCMP monitors a given situation where the car door electrical contact may have inadvertently opened (opened safety circuit) due to the suspected damage whilst the lift was travelling.” Source location Response from Schindler Ltd
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations