PFD report

Lucy Jane PHELAN · Prevention of Future Deaths report

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Issued 1 Apr 2026•Worcestershire

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.

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Concerns
2

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

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 raised2

  1. Failure of alarm monitoring equipment to allow new or different alarms to be distinguished audibly
    Part of recurring concern: Unreliable patient-monitoring alarm systems
  2. Failure of alarm monitoring equipment to record recurrent alarm conditions as new alarms
    Part of recurring concern: Unreliable clinical safety-alert systemsPart of recurring concern: Unreliable patient-monitoring alarm systems
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.1

  1. Action

    Engage the MHRA to establish the manufacturer’s position and understand how alarm-latching functionality should be managed clinically.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The MHRA is the appropriate authority to advise healthcare organisations on medical-device concerns involving alarm-latching capabilities.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 alarm monitoring equipment to allow new or different alarms to be distinguished audibly

Wider context from the report

“While in the resuscitation bay within the Emergency Department at the Alexandra Hospital, Redditch, Ms. Phelan was attached to equipment which monitored her physical observations. These observations are visible on a screen at the patient’s bedside and on a screen at the main nursing station. If a patient’s observations rise or fall outside acceptable parameters, the equipment generates notes both on audible alarm and a visual alarm ( red - higher priority; yellow – lower priority ) on each monitor. The monitoring equipment has a facility known as “latching” which, if activated, means: (a) an alarm will continue to be displayed and sounded even after the conditions which generated it have ended, until it is acknowledged on the monitor, meaning that any alarm for a new or different indication cannot be distinguished audibly; and (b) if the alarm is not acknowledged on the monitor, and the same alarm condition occurs again, this new alarm is not listed in the alarm review or audit log as a new alarm. The inquest heard evidence that “alarm fatigue” is a recognized phenomenon, and that in a busy environment like a hospital’s Emergency Department, particularly when patient numbers are high, staff find it increasingly difficult to react and respond to the many different types of alarm in use. The use of the “latching” facility on monitoring equipment is likely to contribute to this phenomenon; this has been recognized by the equipment manufacturer which no longer recommends its use on Emergency Department monitors, and by Worcestershire Acute Hospitals NHS Trust who have switched it off on monitors in its Emergency Departments. It is not known whether, and to what extent, the “latching” facility remains in use in Emergency Departments in other hospitals in England and Wales. ”

Is this part of a recurring concern?

Yes — Unreliable patient-monitoring alarm systems.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of alarm monitoring equipment to record recurrent alarm conditions as new alarms

Wider context from the report

“While in the resuscitation bay within the Emergency Department at the Alexandra Hospital, Redditch, Ms. Phelan was attached to equipment which monitored her physical observations. These observations are visible on a screen at the patient’s bedside and on a screen at the main nursing station. If a patient’s observations rise or fall outside acceptable parameters, the equipment generates notes both on audible alarm and a visual alarm ( red - higher priority; yellow – lower priority ) on each monitor. The monitoring equipment has a facility known as “latching” which, if activated, means: (a) an alarm will continue to be displayed and sounded even after the conditions which generated it have ended, until it is acknowledged on the monitor, meaning that any alarm for a new or different indication cannot be distinguished audibly; and (b) if the alarm is not acknowledged on the monitor, and the same alarm condition occurs again, this new alarm is not listed in the alarm review or audit log as a new alarm. The inquest heard evidence that “alarm fatigue” is a recognized phenomenon, and that in a busy environment like a hospital’s Emergency Department, particularly when patient numbers are high, staff find it increasingly difficult to react and respond to the many different types of alarm in use. The use of the “latching” facility on monitoring equipment is likely to contribute to this phenomenon; this has been recognized by the equipment manufacturer which no longer recommends its use on Emergency Department monitors, and by Worcestershire Acute Hospitals NHS Trust who have switched it off on monitors in its Emergency Departments. It is not known whether, and to what extent, the “latching” facility remains in use in Emergency Departments in other hospitals in England and Wales. ”

Is this part of a recurring concern?

Yes — Unreliable clinical safety-alert systems; Unreliable patient-monitoring alarm systems.

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

Engage the MHRA to establish the manufacturer’s position and understand how alarm-latching functionality should be managed clinically.

Verbatim wording from the response

“NHS England’s National Patient Safety Team have advised that ‘alarm fatigue’ is a recognised phenomenon and the function ‘alarm latching’ is a setting that requires any triggered alarm to be manually acknowledged and resolved by a member of staff. There are however, other limitations relating to any secondary triggered alarm that may tailor use of this function. The suggestion that ‘the equipment manufacturer no longer recommends the use of alarm latching functionality on the Emergency Department monitors’ is currently subject to further investigation as such information would need to be officially communicated to all users and be part of the medical device manual and Instructions for Use (IFU) documents.”

Source location

Response from NHS England
Page 1 · response
Published 13 April 2026

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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 MHRA is the appropriate authority to advise healthcare organisations on medical-device concerns involving alarm-latching capabilities.

Verbatim wording from the response

“The MHRA are the correct authority to advise on concerns regarding medical devices with alarm latching capabilities healthcare organisations. The NHS England National Patient Safety team will continue to engage with the MHRA to understand how latching functionality is best managed in the clinical environment. The MHRA will be coming back to us once they have gathered further information from the manufacturer regarding this specific case.”

Source location

Response from NHS England
Page 2 · response
Published 13 April 2026

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Discuss all received Regulation 28 reports through the national working group to share learning and identify emerging trends requiring review or action.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
  2. 2

    Share learning from this case with the relevant Integrated Care Board, regional nursing colleagues and the June 2026 Mortality Forum.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 13 April 2026.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The claim that the manufacturer no longer recommends alarm latching on Emergency Department monitors remains subject to investigation.

    Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Discuss all received Regulation 28 reports through the national working group to share learning and identify emerging trends requiring review or action.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Lucy, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 13 April 2026

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

Share learning from this case with the relevant Integrated Care Board, regional nursing colleagues and the June 2026 Mortality Forum.

Verbatim wording from the response

“Midlands regional colleagues have advised that this case will be shared with the relevant Integrated Care Board and with regional nursing colleagues for information and will suggest the possibility of sharing the learning with the Trust Patient Safety Specialists. We have also been advised that learning will also be shared at the Mortality Forum due to be held in June 2026.”

Source location

Response from NHS England
Page 2 · response
Published 13 April 2026

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 claim that the manufacturer no longer recommends alarm latching on Emergency Department monitors remains subject to investigation.

Verbatim wording from the response

“NHS England’s National Patient Safety Team have advised that ‘alarm fatigue’ is a recognised phenomenon and the function ‘alarm latching’ is a setting that requires any triggered alarm to be manually acknowledged and resolved by a member of staff. There are however, other limitations relating to any secondary triggered alarm that may tailor use of this function. The suggestion that ‘the equipment manufacturer no longer recommends the use of alarm latching functionality on the Emergency Department monitors’ is currently subject to further investigation as such information would need to be officially communicated to all users and be part of the medical device manual and Instructions for Use (IFU) documents.”

Source location

Response from NHS England
Page 1 · response
Published 13 April 2026

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