Care home alert systems
Failure of alert systems in care homes to effectively notify staff of residents requiring assistance or at risk.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
89match
Edward Mallaby
The care home lacked a clear policy for handling residents' hazardous personal property, and a sensor mat failed to alert staff to the deceased being out of bed. There was no rapid learning exercise after the incident, and policy reviews lacked completion deadlines.
Matched on
terms: alert, care, home
PFD report
85match
Terence Hawkins
The coroner identified the absence of a system for regular medical monitoring of care home residents and difficulties arranging GP assessments for those unable to attend surgery. Regular GP reviews within the home were suggested to improve care.
Matched on
terms: care, home, system
PFD report
81match
John Edwards
The care home placement was inappropriate for the resident's complex needs, with inadequate falls and pressure sore prevention policies. Staff did not recognise deterioration, seek timely medical assistance, or properly manage medication and care records.
Matched on
terms: care, home
PFD report
77match
Jean Gillespie
The coroner identified that a senior care staff member administering medication was unaware of a resident's life-threatening condition and its urgency. Care home records lacked information on the condition, its symptoms, and the purpose of prescribed medication, presenting a risk if replicated.
Matched on
terms: care, home
PFD report
77match
Jacqueline Scott
Deficiencies were noted in the Philips Respironics Trilogy 202 BIPAP machine's battery alert system and staff training on battery depletion. The ward also lacked an isolated power supply, a mains power failure alert system, and a functional crash bell.
Matched on
terms: alert, system
PFD report
77match
Doris McCarthy
The coroner noted concerns regarding potential ongoing sensor system outages, which could prevent staff from being alerted to resident falls, and raised the need for steps to safeguard residents known to slide when seated in a chair.
Matched on
terms: alert, system
PFD report
77match
Ronald Houchin
The coroner noted that a falls risk assessment was not followed at Rosehill House Care Home, meaning a resident lacked assistance and supervision when mobilising and experienced multiple falls. There is a need for regular falls risk assessments and adherence to care plans.
Matched on
terms: care, home
PFD report
73match
Joseph Godfrey
The coroner identified insufficient awareness among care staff and paramedics regarding the increased bleeding risk for elderly patients on warfarin after a head injury. Concerns were also raised about care home staff not following observation instructions, inadequate record-keeping, and the need for improved training on falls prevention and anticoagulants.
Matched on
terms: care, home
PFD report
73match
Sidney Barnett
The coroner identified inadequate observation, general welfare care, and a lack of clear window opening policies at Berrycroft. Concerns were also raised regarding the Council's safeguarding investigation process, described as vague, unstructured, and over-reliant on care home staff statements.
Matched on
terms: care, home
PFD report
73match
Davin Short
The coroner identified the absence of an electronic system for recording cell bell calls, leading to inconsistent recording of medical matters. They also noted insufficient guidance to ensure single healthcare staff carried a radio, potentially delaying emergency responses.
Matched on
terms: care, system
PFD report
73match
Norman Dorn
The coroner raised concerns that some care homes in Cornwall may lack adequate policies for recognising and confirming death, and for resuscitation. There are also concerns that existing policies might not be regularly updated, or that staff may not be aware of them or adequately trained.
Matched on
terms: care, home
PFD report
73match
Daphne Cherry
The coroner raises concerns about the ability of care home staff to identify when to escalate medical concerns and when a medical review should be sought.
Matched on
terms: care, home
PFD report
73match
Joseph Tarnowski
The coroner noted that the resident may not have been aware his call-bell was portable or able to move it due to mobility issues, and the care home had not considered introducing wearable call bells.
Matched on
terms: care, home
PFD report
73match
Mavis Reeves
The coroner identified limitations with the analogue Careline system that can impede emergency services access and prevent other residents from making calls when the line is in use. Concerns were also raised about insufficient labelling of keys in the safe, leading to delays for emergency services.
Matched on
terms: care, system
PFD report
73match
Sheila Ross
The falls risk assessment tool was outdated, and recorded risk levels did not match the assessment score. The buzzer system's limitations could delay assistance, and poor communication with the family reduced their confidence in care.
Matched on
terms: care, system
PFD report
73match
Gloria Mekins
The coroner raised concerns regarding a Health Care Assistant's failure to provide first aid for choking, a delay in aid due to confusion over a DNA CPR order, and the care home's lack of internal investigation into the incident.
Matched on
terms: care, home
PFD report
73match
Kenneth Clarke
The inquest revealed Normanton Village View Nursing Home lacked formal policies regarding resident observation, food storage, kitchen security, and the care of residents with dementia or those on liquid diets.
Matched on
terms: care, home
PFD report
73match
Anthony Slack
The coroner noted limited documentation and observations at the care home, an unclear COVID-19 origin due to no admission risk assessment, and staff confusion over PPE guidance. Ambulance delays also impacted the transport of vulnerable patients to acute settings.
Matched on
terms: care, home
PFD report
73match
Arthur Johnson
The coroner noted the care home's 'Post-Falls' policy lacked clear direction on when to call emergency services for head injuries, specifically on distinguishing between 'possible' and 'suspected' injuries. There were also concerns about staff training in recognising intracranial injury.
Matched on
terms: care, home
CQC action
70match
Shenstone Hall Nursing Home
The provider must ensure call bells are accessible to the majority of people within communal areas and that call bells for people’s rooms are always answered promptly to facilitate seeking staff assistance.
Matched on
terms: home
PFD report
69match
Joan Wright
The coroner identified gaps in GMP's recognition of safeguarding risks related to medication maladministration and insufficient liaison between police units. The report also notes the lack of a statutory definition for 'regular' medication checks in care homes and an uncorrected oversight regarding CCGs' statutory responsibilities for drugs.
Matched on
terms: care, home
PFD report
69match
Jeanette Robinson
The coroner noted the lack of an alarm or warning system on a medical air mattress and turning device, which meant there was no alert when the power cable dislodged, causing deflation.
Matched on
terms: alert, system
CQC action
69match
St. David's Home
We recommend the provider monitor and assess the use of the call bell system to identify if there are issues with not answering the call bells on time, and if so to identify what these are so they could be addressed.
Matched on
terms: home, system
PFD report
65match
Roger Tombs
The coroner raised concerns that placing fall sensor mats on top of crash mats at Sunrise of Knowle may reduce their effectiveness, potentially failing to alert staff when vulnerable residents mobilise and increasing the risk of falls and injury.
Matched on
terms: alert
PFD report
65match
Ronald Farrington
The coroner noted Nuffield Care Centre's failure to follow tissue viability nurse advice, maintain accurate records, and refer a patient to a GP for infection. Concerns also arose regarding insufficient tissue viability nurse staffing, inadequate CQC evidence collection, and lack of family involvement in reviews.
Matched on
terms: care
PFD report
65match
Robert Lowe
The coroner identified that pressure mats intended to detect residents leaving beds might be bypassed, and audible alarms may not be heard by staff due to their use and operation, especially when multiple alerts are active.
Matched on
terms: alert
PFD report
65match
Edna Davenport
Concerns included inadequate documentation of resident observations and care plans, insufficient information and risk assessment for an aggressive resident, and a failure to conduct neuro observations despite clear head injury signs.
Matched on
terms: care
PFD report
65match
Christine Neild
Concerns were raised regarding easily accessible non-food items for a resident lacking insight, an unescalated prior incident of ingesting non-food items without risk assessment, and the absence of sensors to alert night staff to residents wandering.
Matched on
terms: alert
PFD report
61match
Hilda Cole
The coroner questioned whether the pendant alarm provider adequately informs users, especially those at fire risk, about the option to link their alarm systems with fire alarms. The deceased's family was unaware of this additional facility.
Matched on
terms: system
PFD report
61match
Connor Sparrowhawk
The coroner noted concerns about the effectiveness and practicality of bath time observations for patients with epilepsy, as sound-only monitoring may not prevent drowning. The patient record system (RIO) also lacks a dedicated field for epilepsy history, limiting staff access to vital information.
Matched on
terms: system
PFD report
61match
Margaret Metcalfe
Staff were not alerted by either Mrs Metcalfe's hand-held buzzer or her specialist bed alarm when she got out of bed, leading to her fall.
Matched on
terms: alert
PFD report
61match
Doris Clarkson
The coroner noted that when a bed pressure sensor was removed, a substitute floor pressure mat was not immediately considered to alert staff if the patient left their bed. Regular 15-minute checks were identified as an inadequate alternative to provide timely alerts for falls risk.
Matched on
terms: alert
PFD report
61match
Patrick Kelly
Roseberry Care Centres did not adequately prioritise dental hygiene or dental service provision for residents, which potentially worsened a dental abscess. There were also insufficient policies for managing missed dental appointments and identifying when appointments were required.
Matched on
terms: care
PFD report
61match
Roy Campbell
The coroner noted delays in implementing an electronic system to prevent detained patients from absconding, and that environmental checks to identify means for patients to leave a ward were not consistently carried out or enshrined in Trust policy with mandatory staff training.
Matched on
terms: system
PFD report
61match
Dereck John Chapman
The coroner noted insufficient staff response to a fall by a dementia patient unable to communicate symptoms, and raised concerns about the inaccurate and unreliable quality of nursing home record-keeping.
Matched on
terms: home
PFD report
57match
Jane Dyson Gabbitas
The SHARE accommodation unit lacked a clear system to record and monitor patient absences. This raised concerns that future deaths could occur if action is not taken to track and appropriately respond to prolonged or inappropriate absences.
Matched on
terms: system
PFD report
57match
James McArdle
The withdrawal of a coloured wrist band system for identifying elderly patients at risk of falls, without replacement, removed a layer of protection and may increase the risk of future falls and deaths.
Matched on
terms: system
PFD report
57match
Carl Foot
Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review contributed to a prisoner's death.
Matched on
terms: system
PFD report
57match
Michael Bingham
The coroner identified a 'blind spot' in Harbour Healthcare's risk assessment for internal secure doors lacking alarms, requesting CQC review related guidance and inspection procedures. Concerns also included unclear head/neck injury CT scan guidelines.
Matched on
terms: care
PFD report
57match
Kathleen Devine
Concerns were raised regarding the failure of staff to record observations for a high falls risk resident, the removal of a falls mat and sensor, and the inadequate quality of handover instructions provided to agency staff.
Matched on
classifier match
PFD report
57match
Beryl Walsh
The coroner noted multiple missed opportunities to identify the deceased as a high falls risk, to refer her to the falls team, and to provide falls prevention equipment. No falls risk assessments or care plans had been undertaken.
Matched on
terms: care
PFD report
53match
George Hulme
Agency staff lacked information and adequate induction to identify residents, resulting in an incorrect file retrieval and potentially inappropriate treatment. Resident rooms were also not clearly marked, which could lead to identification confusion during emergencies.
Matched on
classifier match
PFD report
53match
Norman Beard
The coroner identified poor management, a lack of clear policies, and staff and resource shortages due to financial difficulties. Concerns also included delayed referrals for a resident's pressure ulcers and weight loss, and insufficient follow-up on medical advice.
Matched on
classifier match
CQC action
53match
Nottingham City Hospital
The trust must ensure call bell systems are well maintained to keep women and their babies safe.
Matched on
terms: system
LGO / SPSO decision
52match
NIPSO-17159 - Somerton Nursing Home
An investigation has revealed that a nursing home failed to fully record its observations of a resident's head injury following a fall, and did not call an ambulance to take him to hospital until almost eight hours after the incident.
Matched on
terms: home
LGO / SPSO decision
51match
21-014-254 - Somerset County Council
Summary: A care home providing care on behalf of the Council, made several unsuccessful attempts to contact Ms X to notify her of her father’s deteriorating health and his subsequent death. There is no fault in the care home then notifying the second recorded contact.
Matched on
terms: care, home
PFD report
49match
Sandra Wordingham
The coroner highlighted that no medical opinion was sought for a resident remaining unconscious for a prolonged period after a suspected fit, delaying the diagnosis of an intracerebral haemorrhage. This approach places future residents with treatable conditions at risk.
Matched on
classifier match
PFD report
49match
Margaret Connor
The coroner noted insufficient procedures for checking wheelchairs before use, resulting in some being used with missing or faulty footplates. There was also a lack of independent wheelchair checks and doctors were misinformed about a patient's injury despite staff awareness.
Matched on
classifier match
PFD report
49match
Olive Nugent
The coroner noted that the prioritisation of falls activator device responses was subjective, leading to delays for individuals unable to respond verbally, and that staffing levels were insufficient to meet demand.
Matched on
classifier match
PFD report
49match
David Hughes
The report identifies that Level 2 observations were not conducted as prescribed, fluid balance charts were incomplete, and patient bedrooms lacked call bells. Concerns were also raised that staff may not adequately appreciate signs of physical illness.
Matched on
classifier match