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
85match
Terence Hawkins
There was no system for regular medical monitoring of care home residents, with one not seen by a GP for months. Difficulties in arranging assessments for non-attending residents highlighted the need for regular, on-site GP reviews.
Matched on
terms: care, home, system
PFD report
85match
Sheila Ross
The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely assistance, and exhibited poor communication with the family.
Matched on
terms: care, home, system
PFD report
81match
John Edwards
The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor record-keeping, and a failure to administer prescribed medication or seek timely medical assistance for deterioration.
Matched on
terms: care, home
PFD report
77match
George Hulme
Care home agency staff lacked resident identification information and adequate induction. Rooms were not clearly marked, leading to confusion during emergencies and incorrect patient file retrieval for treatment.
Matched on
terms: care, home
PFD report
77match
Jean Gillespie
Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home records also lacked critical information about the condition.
Matched on
terms: care, home
PFD report
77match
Doris McCarthy
Concerns persist about sensor system outages failing to alert staff to falls and inadequate safeguards for residents prone to sliding in chairs.
Matched on
terms: alert, system
PFD report
77match
Christine Neild
The care home failed to prevent residents with learning disabilities from accessing hazardous items, didn't escalate previous incidents, and lacked adequate night staff monitoring for wandering residents.
Matched on
terms: care, home
PFD report
73match
Joseph Godfrey
Care staff and paramedics lacked awareness of warfarin-related bleeding risks in elderly fall patients. Care home staff failed to follow observation protocols, document checks, or access medical history, and BUPA's investigation was insufficient.
Matched on
terms: care, home
PFD report
73match
Sidney Barnett
The care home provided inadequate observation and general welfare for the client, and the subsequent safeguarding investigation was flawed, relying too heavily on unverified staff statements.
Matched on
terms: care, home
PFD report
73match
Davin Short
The prison's lack of an electronic cell bell recording system and unclear guidance on radio use for healthcare staff create risks of medical emergencies being overlooked or delayed, endangering prisoners.
Matched on
terms: care, system
PFD report
73match
Norman Dorn
Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with staff often lacking awareness and proper training.
Matched on
terms: care, home
PFD report
73match
Daphne Cherry
Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.
Matched on
terms: care, home
PFD report
73match
Mavis Reeves
The analogue Careline system caused significant delays for emergency services due to connection times, a single phone line, and key safe access issues, potentially unknown to residents.
Matched on
terms: care, system
PFD report
73match
Joan Wright
Issues included inconsistent opioid handling, unaddressed statutory oversight for drug responsibilities, police failure to recognise safeguarding risks in medication errors, and a lack of statutory definition for "regular" medication checks in care homes.
Matched on
terms: care, home
PFD report
73match
Edna Davenport
The care home failed to provide a disabled patient with a call alarm or adequate observations, lacked documentation for care plans, and did not properly assess or manage the risk posed by an aggressive resident, leading to an assault and neglect of head injury monitoring.
Matched on
terms: care, home
PFD report
73match
Dereck John Chapman
Nursing home staff provided an insufficient response to a high-fall-risk dementia patient, failing to account for his communication difficulties. Additionally, poor and unreliable record-keeping compromised accurate care narrative and incident review.
Matched on
terms: care, home
PFD report
73match
Anthony Slack
The care home suffered from poor documentation and observation quality, unclear Covid-19 infection control (no admission risk assessment), and staff confusion over PPE. Ambulance delays also impacted patient transfer.
Matched on
terms: care, home
PFD report
73match
Arthur Johnson
Care home's "Post-Falls" policy lacked clarity on when to call emergency services for possible head injuries, and staff training on recognising intracranial injury was insufficient.
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
Phylliss Letcher
The care home lacked live CCTV monitoring for staircases, had no key fob access control, and no alarm if the stairgate was left open, creating unrestricted access to dangerous areas.
Matched on
terms: care, home
PFD report
69match
Gloria Mekins
A Health Care Assistant failed to perform first aid during a choking incident, and confusion over a DNA CPR order caused delays. The care home also failed to investigate or identify these critical issues internally.
Matched on
terms: care, home
PFD report
69match
Edward Mallaby
The care home lacked clear policy for handling hazardous personal property and a functioning sensor mat for falls detection. Observation protocols were unclear, and no rapid learning exercise followed the incident.
Matched on
terms: care, home
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
Jane Dyson Gabbitas
An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being unaware of a resident's prolonged disappearance until her body was discovered.
Matched on
terms: system
PFD report
65match
Jacqueline Scott
The BIPAP machine's battery alarm is visually obscured and lacks a distinct sound, hindering staff recognition of critical power loss due to inadequate training. The ward lacked isolated power supply, and there was no system to detect mains power failure.
Matched on
terms: system
PFD report
65match
Joseph Tarnowski
A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility limitations, highlighting a lack of consideration for alternative wearable alarm systems.
Matched on
terms: system
PFD report
61match
Sandra Wordingham
A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe condition and risking unnecessary death if early intervention was possible.
Matched on
terms: home
PFD report
61match
Connor Sparrowhawk
The bath time observation policy for epileptic patients is inadequate, with concerns about the effectiveness of sound-only monitoring and potential staff distraction. The RIO system also lacks sufficient fields for comprehensive epilepsy information, hindering staff access.
Matched on
terms: system
PFD report
61match
Margaret Metcalfe
Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of bed, resulting in a fall that was only discovered by hearing a 'thud'.
Matched on
terms: alert
PFD report
61match
Ronald Farrington
The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for infection, exacerbated by inadequate tissue viability nurse staffing and poor CQC oversight.
Matched on
terms: care
PFD report
61match
Roy Campbell
Inadequate systems to prevent detained patients from absconding included a flawed visitor tracking system and environmental checks not properly implemented or enshrined in policy with mandatory staff training.
Matched on
terms: system
PFD report
61match
Kenneth Clarke
The nursing home lacked formal policies for crucial areas including resident observation, food storage security, managing dementia residents, and caring for patients on liquid diets.
Matched on
terms: home
PFD report
57match
James McArdle
The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the risk of falls for elderly patients.
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
Harbour Healthcare failed to implement alarms for insecure internal doors, highlighting a risk assessment "blind spot." The CQC must review regulations and inspection procedures for door safety, and Stockport NHS guidelines lack clarity on CT scan requirements.
Matched on
terms: care
PFD report
57match
Beryl Walsh
There were multiple missed opportunities to identify the deceased as a high falls risk, escalate care to the falls team, or implement falls prevention equipment and assessments.
Matched on
terms: care
PFD report
57match
Patrick Kelly
Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for managing missed appointments or identifying dental care needs.
Matched on
terms: care
PFD report
53match
Olive Nugent
Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving vulnerable individuals without timely assistance.
Matched on
classifier match
PFD report
53match
Kathleen Devine
A high-risk falls resident sustained injuries due to an unplugged falls mat, unrecorded observations, and inadequate handover information for agency staff regarding critical safety measures.
Matched on
classifier match
PFD report
53match
Robert Lowe
Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.
Matched on
classifier match
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
Margaret Connor
Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about a patient's injury despite staff and family concerns.
Matched on
classifier match
PFD report
49match
Hilda Cole
The pendant alarm provider failed to adequately inform customers about additional safety features, specifically the option to link to fire alarms, creating an unaddressed fire risk for vulnerable users.
Matched on
classifier match
PFD report
49match
David Hughes
Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, and nursing staff showed insufficient understanding of physical illness signs.
Matched on
classifier match
PFD report
49match
Norman Beard
Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed specialist referrals and ignored medical advice compounded the patient's deteriorating condition.
Matched on
classifier match
PFD report
49match
Roger Tombs
Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of undetected falls, injury, and death for vulnerable residents.
Matched on
classifier match
PFD report
49match
Doris Douthwaite
Vulnerable residents with dementia were left unsupervised due to unclear policies, an ambiguous falls risk assessment tool, and a lack of investigation into multiple falls, missing learning opportunities.
Matched on
classifier match
PFD report
49match
Anne Roberts
Inadequate training for bank staff on choking risks, poor dissemination of this information in patient records, and difficulties managing choking risks alongside self-harm concerns for patients eating in bedrooms were identified.
Matched on
classifier match
PFD report
49match
Ronald Houchin
Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable falls for the patient.
Matched on
classifier match