FirstPort Retirement
Other
Action Taken
FirstPort has separated the master key in the key safe and stored it prominently. They investigated installing Safelink and an emergency telephone line at the entry gate, but concluded neither would add a further method of entry for emergency services. (AI summary)
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UK-611129600.1 IN THE BEDFORSHIRE AND LUTON CORONER’S COURT IN THE MATTER OF:
The Inquest Touching the Death of Mavis Jeanne Reeves Response to Ian Pears’ Regulation 28 Report (Action to Prevent Future Deaths) From FirstPort Retirement Property Services Limited
1. INTRODUCTION
1.1 This document sets out the response of FirstPort Retirement Property Services Limited (“FirstPort”) to paragraph 5 of Ian Pears’ Regulation 28 report dated 6 February 2018 (the “Report”). For the ease of reference the Coroners matters of concern detailed at paragraph 5 of the Report are set out below: 5(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 First, do residents know of the limitation with 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. 5(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 caller 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. 5(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.
1.2 The above matters of concern are dealt with individually at paragraphs 2 to 4.
2. PARAGRAPH 5(1)
2.1 We will address your two concerns raised within this paragraph in turn.
2.2 However, prior to addressing your concerns we would like to provide some background information regarding the system in place.
UK-611129600.1 2
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.
2.2.2 When the upgrade was completed in 2014, all residents were informed of how the system works and the various entry methods. The entry system is also discussed with new residents on their new resident induction.
2.3 First, do the residents know if the limitation within the Careline System currently installed.
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.
2.3.2 The residents discussed the option of changing the system to a digital system however they have confirmed that they are happy with the current system and do not wish to change from the current system.
2.4 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.
2.4.1 As set out within the Report, there are four ways for the emergency services to gain access to the premises as a non-resident. Whilst the system in place at the time of the incident is recognised as an acceptable and fit for purpose system, it is recognised however that on the day in question the code provided was not correct.
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.
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.
2.4.4 Whilst the system in place is of the required standard, we are committed to ensuring the safety of the residents and as such, we have looked into whether any further safety measures could be put in place to ensure that the emergency services can have access to the premises without delay. (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
UK-611129600.1 3 this type of interaction; it was concluded therefore that installing Safelink would not add a further method of entry for the emergency services. (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.
3. PARAGRAPH 5(2)
3.1 We set out our response in respect to communicating the potential limitations with the analogue system, as outlined by the Coroner, in paragraph 2.2 above.
4. PARAGRAPH 5(3)
4.1 At the time of the incident all keys were clearly labelled and stored in the key safe at the main entrance. The safe has a speech module and pull cord as is industry standard. However, we note the Coroners concern that despite this control measure the paramedic had difficulty locating the master key and as an additional control measure we have therefore separated this key from the bunch of keys and it is stored separately and prominently within the key safe.
The Inquest Touching the Death of Mavis Jeanne Reeves Response to Ian Pears’ Regulation 28 Report (Action to Prevent Future Deaths) From FirstPort Retirement Property Services Limited
1. INTRODUCTION
1.1 This document sets out the response of FirstPort Retirement Property Services Limited (“FirstPort”) to paragraph 5 of Ian Pears’ Regulation 28 report dated 6 February 2018 (the “Report”). For the ease of reference the Coroners matters of concern detailed at paragraph 5 of the Report are set out below: 5(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 First, do residents know of the limitation with 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. 5(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 caller 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. 5(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.
1.2 The above matters of concern are dealt with individually at paragraphs 2 to 4.
2. PARAGRAPH 5(1)
2.1 We will address your two concerns raised within this paragraph in turn.
2.2 However, prior to addressing your concerns we would like to provide some background information regarding the system in place.
UK-611129600.1 2
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.
2.2.2 When the upgrade was completed in 2014, all residents were informed of how the system works and the various entry methods. The entry system is also discussed with new residents on their new resident induction.
2.3 First, do the residents know if the limitation within the Careline System currently installed.
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.
2.3.2 The residents discussed the option of changing the system to a digital system however they have confirmed that they are happy with the current system and do not wish to change from the current system.
2.4 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.
2.4.1 As set out within the Report, there are four ways for the emergency services to gain access to the premises as a non-resident. Whilst the system in place at the time of the incident is recognised as an acceptable and fit for purpose system, it is recognised however that on the day in question the code provided was not correct.
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.
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.
2.4.4 Whilst the system in place is of the required standard, we are committed to ensuring the safety of the residents and as such, we have looked into whether any further safety measures could be put in place to ensure that the emergency services can have access to the premises without delay. (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
UK-611129600.1 3 this type of interaction; it was concluded therefore that installing Safelink would not add a further method of entry for the emergency services. (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.
3. PARAGRAPH 5(2)
3.1 We set out our response in respect to communicating the potential limitations with the analogue system, as outlined by the Coroner, in paragraph 2.2 above.
4. PARAGRAPH 5(3)
4.1 At the time of the incident all keys were clearly labelled and stored in the key safe at the main entrance. The safe has a speech module and pull cord as is industry standard. However, we note the Coroners concern that despite this control measure the paramedic had difficulty locating the master key and as an additional control measure we have therefore separated this key from the bunch of keys and it is stored separately and prominently within the key safe.