PFD report

MAVIS JEANNE REVES · Prevention of Future Deaths report

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Issued 6 Feb 2018•Bedfordshire and Luton

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Failure to clearly label keys in the key safe
  2. Delays in analogue Careline connection
    Part of recurring concern: Unreliable call bell systems for summoning assistance
  3. Failure of the analogue Careline system to support concurrent emergency access and calls
    Part of recurring concern: Failure to ensure emergency services have reliable, timely access to shared accommodationPart of recurring concern: Unreliable access to emergency communicationPart of recurring concern: Unreliable emergency access arrangements for responders
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Store the master key separately and prominently within the entrance key safe.

    Stated by FirstPort Retirement Property Services LimitedStated completedThe respondent said that this action was complete when they made their response on 7 June 2018.
  2. Action

    Inform residents about Careline entry methods and analogue-system limitations through a meeting and written follow-up.

    Stated by FirstPort Retirement Property Services LimitedStated completedThe respondent said that this action was complete when they made their response on 7 June 2018.
  3. Action

    Ensure Appello Careline systems display the correct access codes for each managed development to operators.

    Stated by FirstPort Retirement Property Services LimitedStated completedThe respondent said that this action was complete when they made their response on 7 June 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The existing analogue entry system is industry-accepted, fit for purpose, and residents do not wish to replace it with a digital system.

    Stated by FirstPort Retirement Property Services LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable call bell systems for summoning assistance.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to ensure emergency services have reliable, timely access to shared accommodation; Unreliable access to emergency communication; Unreliable emergency access arrangements for responders.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to ensure emergency services have reliable, timely access to shared accommodation.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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
Page 2 · response
Published 7 June 2018

Open published response

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
Page 2 · response
Published 7 June 2018

Open published response

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
Page 2 · response
Published 7 June 2018

Open published response

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
Page 2 · response
Published 7 June 2018

Open published response

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
Page 3 · response
Published 7 June 2018

Open published response

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
Page 2 · response
Published 7 June 2018

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026