PFD report

Steven Paul KIRKHAM · Prevention of Future Deaths report

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Issued 18 Aug 2021•South Yorkshire (Eastern)

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 to inform users of door alarm mechanisms about potential dangers
  2. Blind spot in the relevant area
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

    Amend the door-alarm design by adding a mechanical fixing between the hinge and alarm, and notify NHS trusts that the redesigned alarm is available.

    Stated by Intastop LimitedStated completedThe respondent said that this action was complete when they made their response on 26 August 2021.

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 inform users of door alarm mechanisms about potential dangers

Wider context from the report

“(2) I have been informed that, although Swallownest have replaced the doors with an alternative, that these door alarm systems may still be used in a variety of places where vulnerable people are housed. I am concerned that other users of these mechanisms may not have been informed of the potential danger. (3) I was not given any information with regard to what, if anything, has been done to rectify the “blind spot” area by Instatop and therefore have concerns that other users of the doors may be unaware of the issue. ”

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

Blind spot in the relevant area

Wider context from the report

“(1) It appears that there is a “blind spot” on the ████████ ████████. ”

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

Amend the door-alarm design by adding a mechanical fixing between the hinge and alarm, and notify NHS trusts that the redesigned alarm is available.

Verbatim wording from the response

“The Intastop door top alarm is designed to reduce the risk of ████████. Unfortunately it is impossible to completely eliminate any chance of ████████ and this has been communicated to all users of the product. However, in response to this tragic event, and in an effort to prevent any future death, our client has undertaken the following actions:”

Source location

2021-0280-Response-from-Instastop-Ltd_Published-1
Page 2 · response
Published 26 August 2021

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.5

  1. 1

    Continue working with NHS trusts to communicate and trial new door-alarm designs that improve safety.

    Stated by Intastop LimitedStated in progressThe respondent said that this action was in progress when they made their response on 26 August 2021.
  2. 2

    Remind trusts to maintain Intastop products according to the fitting instructions and operation and maintenance manual, including available preventative maintenance support.

    Stated by Intastop LimitedStated completedThe respondent said that this action was complete when they made their response on 26 August 2021.
  3. 3

    Investigate the incident, inspect available door alarms, verify their operation, and share the findings with the relevant NHS Trusts.

    Stated by Intastop LimitedStated completedThe respondent said that this action was complete when they made their response on 26 August 2021.
  4. 4

    Further redesign the alarm to reduce risk and live-trial the revised design at another NHS Trust.

    Stated by Intastop LimitedStated in progressThe respondent said that this action was in progress when they made their response on 26 August 2021.
  5. 5

    Retrain Swallownest staff on when and how to check and reset the door alarms using the operation and maintenance manual.

    Stated by Intastop LimitedStated completedThe respondent said that this action was complete when they made their response on 26 August 2021.

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

Continue working with NHS trusts to communicate and trial new door-alarm designs that improve safety.

Verbatim wording from the response

“HM Coroner can be confident that Intastop continuously looks to improve its existing product range and/or introduce new products to ensure it is meeting the needs of its customer and reducing ████████ risk as much as possible. Intastop has always, and continues to work closely and actively with Trusts as regards communicating and trialling new product designs.”

Source location

2021-0280-Response-from-Instastop-Ltd_Published-1
Page 3 · response
Published 26 August 2021

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

Remind trusts to maintain Intastop products according to the fitting instructions and operation and maintenance manual, including available preventative maintenance support.

Verbatim wording from the response

“• All trusts were reminded that products installed by Intastop must be maintained as per Intastop’s fitting instructions and/or the operation and maintenance manual. Trusts were also made aware of the planned preventative maintenance that was available through Intastop.”

Source location

2021-0280-Response-from-Instastop-Ltd_Published-1
Page 2 · response
Published 26 August 2021

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

Investigate the incident, inspect available door alarms, verify their operation, and share the findings with the relevant NHS Trusts.

Verbatim wording from the response

“HM Coroner may be assured that our client undertook a comprehensive investigation in response to this incident, the findings of which were shared with Rotherham, Doncaster and South Humber NHS Trust on 9 April 2019. A copy is enclosed for HM Coroner’s attention.”

Source location

2021-0280-Response-from-Instastop-Ltd_Published-1
Page 2 · response
Published 26 August 2021

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

Further redesign the alarm to reduce risk and live-trial the revised design at another NHS Trust.

Verbatim wording from the response

“• The alarm has since been further re-designed to reduce the risk of ████████ even further and this is currently being live trialled at another NHS Trust.”

Source location

2021-0280-Response-from-Instastop-Ltd_Published-1
Page 2 · response
Published 26 August 2021

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

Retrain Swallownest staff on when and how to check and reset the door alarms using the operation and maintenance manual.

Verbatim wording from the response

“• As it was apparent from the post incident investigation that there was inconsistency when re-setting the door alarms, staff at Swallowdale were re-trained on how and when to check the alarms as detailed in the operation and maintenance manual.”

Source location

2021-0280-Response-from-Instastop-Ltd_Published-1
Page 2 · response
Published 26 August 2021

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