Care home alert systems
Failure of alert systems in care homes to effectively notify staff of residents requiring assistance or at risk.
Source spread
Where this theme appears
This theme appears across 8 independent accountability sources, so the source mix matters as much as the headline total.
92 PFD reports
3 CQC actions
4 PPO recs
2 IMB recs
1 patient safety alert
1 Scottish FAI
1 PHSO decision
4 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Prevention of Future Deaths reports(92)— showing 50 strongest matches
Sandra Wordingham
Concerns: 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.
Response (Springbank Nursing Home): Springbank Nursing Home has produced a protocol for managing unconscious residents, including training for staff, clearer risk assessments, and mandatory summoning of emergency services in cases of doubt. The protocol …
Responded
Jane Dyson Gabbitas
Concerns: 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.
Overdue
Joseph Godfrey
Concerns: 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.
Overdue
Margaret Connor
Concerns: 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.
Response (Heathers Nursing Home): The nursing home asserts it already meets required standards for equipment maintenance and staff training. They are implementing weekly wheelchair checks and providing staff with updated guidelines, including a wheelchair …
Responded
James McArdle
Concerns: The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the risk of falls for elderly patients.
Response (Wirral University Teaching Hospitals NHS Foundation Trust): The Trust is developing a new policy specific to patient falls, providing clearer guidance on risk assessments and timescales, and will communicate changes to nursing staff and revise audit questionnaires …
Responded
Hilda Cole
Concerns: 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.
Overdue
George Hulme
Concerns: 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.
Overdue
Olive Nugent
Concerns: Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving vulnerable individuals without timely assistance.
Overdue
Sidney Barnett
Concerns: 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.
Response: The care home has implemented room visit charts, enhanced personal care documentation, dignity training delivered by the manager, and window checks as part of the room visit checks.
Overdue
Davin Short
Concerns: 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.
Response (HMP Weyland): HMP Wayland published a Governor's Order clarifying the recording of medical issues occurring overnight and amended the Local Security Strategy to support this. They also introduced a new radio system …
Response (HM Prison and Probation Service): HMP Wayland has issued a Governor's Order instructing staff to record medical issues during the night in the wing observation book and amended the Local Security Strategy to reflect this …
Responded
Carl Foot
Concerns: 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.
Overdue
Jean Gillespie
Concerns: 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.
Response (MMCG): Senior Care Assistants received further medication training and competency assessments, including a supervision after the inquest. The new manager introduced handover and medication count down sheets for improved communication and …
Responded
Connor Sparrowhawk
Concerns: 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.
Response (Southern Health NHS Foundation Trust): A new protocol for safe bathing and showering of people with epilepsy has been drafted, and is undergoing consultation. A change request has been made for a prompt in the …
Overdue
Norman Dorn
Concerns: 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.
Overdue
David Hughes
Concerns: 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.
Response (David Hughes): The Trust has completed a cycle of recruitment into new general nurse posts at the Bradgate Unit and has commenced a second cycle; the service will review this strategy and …
Responded
Margaret Metcalfe
Concerns: 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'.
Response (Stockton on Tees Borough Council): Rosedale Centre implemented a new policy regarding Care Assist pagers, including staff responsibilities for checking equipment, documenting its use, responding to alerts, and reporting problems, with monthly audits by the …
Responded
Jacqueline Scott
Concerns: 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.
Response (Department of Health): The Department of Health acknowledged concerns about BiPAP machine design and power supply resilience. It will review relevant sections of the Hospital Technical Memorandum (HTM) as part of its wider …
Response (St George's University Hospitals NHS Foundation Trust): St George's will install a UPS/IPS backup system in the Richmond ADU, with completion expected in summer 2016, to address power supply concerns. Nursing staff are also undertaking twice-weekly checks …
Overdue
Stanley Sampey
Concerns: The ward lacked working suction equipment due to a flat battery and an incorrect, unstructured checking procedure, posing a risk to patient airway management.
Overdue
Terence Hawkins
Concerns: 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.
Response (Lime Tree Surgery): The surgery will conduct a survey of visit requests by the home and seek feedback on how to improve the process. They have a lower threshold for home visit requests …
Responded
Norman Beard
Concerns: 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.
Overdue
Roger Tombs
Concerns: 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.
Response (Sunrise Senior Living): Sunrise Senior Living acknowledges the report but states it is leaving the Home's management and registration with CQC on 1 March 2017. It invites dialogue and can describe immediate actions …
Response (Roger Tombs): The Falls Team reviewed its practices after the PFD report and found them consistent and accurate. A guidance document outlining good practice in sensor mat use was developed and sent …
Overdue
Doris Clarkson
Concerns: Concerns relate to the lack of a substitute pressure sensor mat after removal, incompatibility between a new mattress and the sensor, and the inadequacy of 15-minute checks for a patient with a history of falls.
Response (Lambton House Care Home): Lambton House is phasing in air flow mattresses compatible with bed sensors and installs bed sensors for users at risk of falls who do not require an air flow mattress. …
Responded
Daphne Cherry
Concerns: Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.
Response (Care UK): Care UK has taken actions including training the home manager, deputy, and unit leaders in early recognition of deteriorating patients, delivering training to all staff, introducing daily meetings and walkarounds …
Responded
Joseph Tarnowski
Concerns: 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.
Response (Hillbrook Grange): Following the inquest, Hillbrook Grange Residential Care Home immediately provided residents with call bells to be worn around their necks.
Responded
Michael Bingham
Concerns: 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.
Response: Harbour Healthcare has completed work on internal doors at Hilltop Court, installing screech alarms or box panels, and has fitted screech alarms to internal emergency exit doors at other care …
Overdue
Ronald Farrington
Concerns: 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.
Response: Surrey County Council has improved systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion, and has reduced the percentage of enquiries …
Response (Ronald Farrington): The care home has implemented structures and processes to avoid similar situations, including computerized care plans for wound and tissue care, regular reviews, and updates based on professional visits, audited …
Overdue
Kathleen Devine
Concerns: 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.
Response (Bloom Care): The care home has implemented several changes including creating care plans for residents with crash/sensor mats, adding information to handover sheets, adding an extra column on mattress check sheets, updated …
Overdue
John Edwards
Concerns: 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.
Response (Response Southwinds Limited): Response Southwinds Limited disputes the implication that neglect contributed to the death of Mr. Edwards, argues that other evidence was not sufficiently taken into account, and asserts that they were …
Overdue
Mavis Reeves
Concerns: 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.
Response (FirstPort Retirement): 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 …
Responded
Sheila Ross
Concerns: 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.
Overdue
Doris McCarthy
Concerns: Concerns persist about sensor system outages failing to alert staff to falls and inadequate safeguards for residents prone to sliding in chairs.
Overdue
Phylliss Letcher
Concerns: 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.
Response (Anson Care Services Limited): The organisation is looking into whether it is possible to have an alarm which is audible to carers and identifies which stairgate is open.
Responded
Joan Wright
Concerns: 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.
Response (Department of Health): The Department of Health outlines existing regulations and guidance regarding controlled drugs, referencing the Shipman Inquiry, the Controlled Drugs Regulations 2006, NICE guidelines and CQC guidance; the Department suggests taking …
Responded
Doris Douthwaite
Concerns: 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.
Overdue
Anne Roberts
Concerns: 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.
Overdue
Beryl Walsh
Concerns: 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.
Response (Beechwood Lodge): Beechwood Lodge has put in place more robust risk assessments for residents who have had falls, documenting all conversations with relatives and professionals. They have added new risk assessments in …
Responded
Ronald Houchin
Concerns: Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable falls for the patient.
Overdue
Patrick Kelly
Concerns: 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.
Response (Roseberry Care): The care home has implemented a Resident of the Day procedure for care file updates, reviews of care plans, and a diary record for tracking residents' dental care; staff have …
Responded
Gloria Mekins
Concerns: 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.
Response (Rossmere Park Care Centre): The care centre disputes the coroner's assertion that staff believed the deceased was choking. Following a Lessons Learned Meeting, they implemented a protocol for staff to follow after a death …
Overdue
Jeanette Robinson
Concerns: The coroner raises concerns about the lack of an alarm on a Nimbus 3 air mattress, which deflated when its power cable was dislodged, contributing to the patient's death.
Response (Cornwall Council): Cornwall Council has replaced all Nimbus mattress systems in the community with Elite systems. All Nimbus stock has been destroyed. The council states that the previous service records indicate that …
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA explains CE marking and post-market surveillance processes for medical devices like mattresses, noting that the incident was not reported to them. They state that without a serial number …
Responded
Robert Lowe
Concerns: Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.
Overdue
Eileen Pollard
Concerns: Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't recorded, potentially endangering patients if call bells are non-functional.
Overdue
Roy Campbell
Concerns: 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.
Response (Worcestershire Health and Care NHS Trust): The Trust is implementing environmental risk assessment forms on wards, with completion covered in new staff inductions and existing staff supervision sessions. While a business case for an electronic visitor …
Responded
Edna Davenport
Concerns: 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.
Overdue
Kenneth Clarke
Concerns: 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.
Overdue
Dereck John Chapman
Concerns: 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.
Response (Rossendale Nursing Home): Rossendale Nursing Home has implemented Person Centred Software, walk around handovers, pre-admission falls risk assessments, motion sensors, staff presence in communal areas, a post-fall protocol, referrals to the Falls team, …
Responded
Christine Neild
Concerns: 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.
Response (Meade Close Care Home): Meade Close Care Home has provided additional training to all staff on identifying risks and escalating concerns, as well as on safeguarding adults and children, basic life support, and first …
Response (Responses from Trafford Council and CQC): Trafford Council reiterated PPE guidance and will conduct bi-annual audits to ensure adherence, monitored via a specific audit tool and annual quality review.
Responded
Anthony Slack
Concerns: 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.
Response (NHS England and NHS Digital): NHS England liaised with the North West Ambulance Service (NWAS) who have since extended their cleaning service to sixteen Emergency Departments across the North West, including Tameside Hospital, to improve …
Response (UK Health Security Agency): PHE acknowledges the coroner's report and outlines its national activities coordinating the response to COVID-19 in adult social care settings, including surveillance, guidance development, and stakeholder engagement. It states that …
Response (CQC): CQC reviewed systems at The Vicarage Residential Care Home and is assured that the provider has taken action to improve and further reduce risks, which will be reviewed at the …
Response (Greater Manchester Health and Social Care Partnership): Greater Manchester Health and Social Care Partnership will present learning to the Greater Manchester Quality Board. They have established an Infection Prevention and Control Care Home Cell, are running monthly …
Response (Vicarage Care Home): The Vicarage Care Home has provided documentation training to staff, updated the documentation and recording policy, reissued relevant documentation pro formas, and updated the protocol regarding waiting times for emergency …
Responded
Edward Mallaby
Concerns: 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.
Response (Roseberry Care Centres): Roseberry Care Centres updated policies regarding residents' belongings, admission of residents, and falls management, issuing them to all homes with 'read and sign' sheets and discussing changes in small group …
Responded
Arthur Johnson
Concerns: 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.
Response (Hampshire County Council): Hampshire County Council updated its "falls protocol" in line with current NICE guidance, clarifying that staff should contact 999 or 111. Additionally, staff will now participate in a standalone learning …
Responded
CQC inspection actions(3)
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.
Must Do
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 …
Should Do
The Goddards
The provider must ensure recorded checks are completed to ensure that the equipment used by the service provider for providing care to a person was safe for such use and used in a safe way.
Must Do
PPO death in custody recommendations(4)
The Governor of HMP Lewes
The Governor will wish to assure himself that cell bells are being answered promptly.
The Governor of HMP Wandsworth
The Governor should provide the Ombudsman with a clear plan outlining how they will improve cell bell response times.
The Governor
The Governor should carry out a review to: Establish whether personal alarms can be clearly heard by wing staff throughout the day and night, or whether proximity of the cell to the wing office should be considered when issuing one. …
The Head of Healthcare
The Head of Healthcare should address the provision of a pressure-relieving mattress.
IMB individual recommendations(2)
National patient safety alerts(1)
Scottish Fatal Accident Inquiries(1)
LGO / SPSO decisions(4)
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.
NIPSO (NI Public Service…
Health & Social Care
Mar 2018
24-006-066 — London Borough of Newham
Summary: We will not investigate this complaint about delays in responding to the elderly alarm service. We could not add to the Council’s investigation or reach a worthwhile outcome. We are satisfied with the actions the Council took to acknowledge the distress caused by failures in its complaint handling.
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2024
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.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jul 2022
22-004-973 — North Northamptonshire Council
We will not investigate this complaint as we are unlikely to find fault in the Council’s actions.
LGO (Local Government & …
Environment And Regulation
Aug 2022