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 10 independent accountability sources, so the source mix matters as much as the headline total.
92 PFD reports
5 CQC actions
4 PPO recs
2 IMB recs
1 patient safety alert
1 Scottish FAI
4 DHR recs
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: 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.
Response (Springbank Nursing Home): • The nursing home dismissed one nurse and initiated disciplinary proceedings against another following an internal investigation. • The nursing home provided all nurses with the Nursing & Midwifery Council … (AI summary)
Responded
Jane Dyson Gabbitas
Concerns: 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.
Overdue
Joseph Godfrey
Concerns: 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.
Overdue
Margaret Connor
Concerns: 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.
Response (Heathers Nursing Home): • All staff received updated health and safety guidance and a written directive on wheelchair use and management. • Wheelchairs were numbered, allocated to residents, and their footplates were checked … (AI summary)
Responded
James McArdle
Concerns: 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.
Response (Wirral University Teaching Hospitals NHS Foundation Trust): • The Trust resolved in October 2013 to use red wristbands for allergies only, communicating this change to staff. • The Trust implemented new assisted technology and improved comfort checks, … (AI summary)
Responded
Hilda Cole
Concerns: 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.
Overdue
George Hulme
Concerns: 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.
Overdue
Olive Nugent
Concerns: 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.
Overdue
Sidney Barnett
Concerns: 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.
Response: • The care home implemented a new room visit chart for all residents, requiring hourly checks and 15-minute checks if meals are taken in rooms. • All personal care forms … (AI summary)
Overdue
Davin Short
Concerns: 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.
Response (HMP Weyland): • HMP Wayland published a Governors Order and amended its Local Security Strategy to clarify the recording of medical issues during the night. • A new radio system has been … (AI summary)
Response (HM Prison and Probation Service): • A Governor's Order was issued at HMP Wayland, instructing staff to record medical issues occurring during the night in the wing observation book. • The Local Security Strategy was … (AI summary)
Responded
Carl Foot
Overdue
Jean Gillespie
Concerns: 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.
Response (MMCG): • Senior Care Assistants received further medication training and competency assessments. • Supervisions were completed to reinforce medication management policies and procedures. • A new manager introduced handover sheets and … (AI summary)
Responded
Connor Sparrowhawk
Concerns: 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.
Response (Southern Health NHS Foundation Trust): • A new Protocol for the Safe Bathing and Showering of People with Epilepsy has been drafted, consulted upon, and is being finalised for ratification, with the draft already circulated … (AI summary)
Responded
Norman Dorn
Concerns: 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.
Overdue
David Hughes
Concerns: 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.
Response (David Hughes): • A new Therapeutic Observation Policy was implemented in 2015, including staff competency-based training and checks, and disciplinary action was taken against staff involved in the incident. • The service … (AI summary)
Responded
Margaret Metcalfe
Concerns: 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.
Response (Stockton on Tees Borough Council): • Care Assist pagers and charging units were checked, re-labelled, and their charging units relocated for management oversight. • A written procedure was implemented for staff, covering risk assessment, equipment … (AI summary)
Responded
Jacqueline Scott
Concerns: 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.
Response (Department of Health): • NHS England and the MHRA issued a Patient Safety Alert in February 2015 concerning the risk of harm from unintentional interruption of non-invasive ventilation. • The MHRA plans to … (AI summary)
Response (St George's University Hospitals NHS Foundation Trust): • Staff received retraining on non-invasive ventilation and the Trilogy machine, and a dedicated practice educator was employed. • An external expert was engaged to advise on electrical infrastructure, leading … (AI summary)
Overdue
Stanley Sampey
Concerns: The coroner noted the absence of working suction equipment on the ward during a cardiac arrest and identified a lack of a structured checking procedure to ensure its functionality and properly charged batteries.
Overdue
Terence Hawkins
Concerns: 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.
Response (Lime Tree Surgery): • The surgery conducted an in-house Significant Event Analysis, which resulted in a lower threshold for home visit requests for the care home. • The surgery committed to conducting a … (AI summary)
Responded
Norman Beard
Concerns: 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.
Overdue
Roger Tombs
Concerns: 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.
Response (Sunrise Senior Living): • Sunrise Senior Living stated it took steps immediately following the inquest to address concerns regarding the placement of sensor mats on crash mats. • Sunrise Senior Living invited the … (AI summary)
Response (Roger Tombs): • The Falls Team reviewed its practice regarding advice and training on sensor mats and found it to be consistent and accurate. • A guidance document outlining good practice in … (AI summary)
Overdue
Doris Clarkson
Concerns: 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.
Response (Lambton House Care Home): • Pressure mats are now standard practice for mattresses incompatible with bed sensors. • The care home is phasing in air flow mattresses that are compatible with bed-based pressure sensors. … (AI summary)
Responded
Daphne Cherry
Concerns: 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.
Response (Care UK): • Home managers, deputy managers, and unit leaders have undergone training in 'Early recognition of the sick and deteriorating patient'. • Unit leaders are tasked with cascading training principles, including … (AI summary)
Responded
Joseph Tarnowski
Concerns: 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.
Response (Hillbrook Grange): • Hillbrook Grange provided residents with call bells designed to be worn around their necks. • The board of directors approved this recommendation, and the system was implemented within a … (AI summary)
Responded
Michael Bingham
Concerns: 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.
Response: • Harbour Healthcare confirmed the installation of alarms or box panels on internal doors across its care homes, implemented new procedures, and conducted risk assessments. • The CQC issued a … (AI summary)
Overdue
Ronald Farrington
Concerns: 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.
Response: • Surrey County Council Adult Social Care services completed an adult safeguarding enquiry with Nuffield Care and the family. • Systems were improved to identify and reduce the number of … (AI summary)
Response (Ronald Farrington): • The care centre implemented a new auditing system for wound care, involving weekly manager audits and monthly general manager and senior management team reviews. • A formal wound assessment … (AI summary)
Overdue
Kathleen Devine
Concerns: 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.
Response (Bloom Care): • A precise care plan has been implemented for residents using crash or sensor mats, detailing guidance for staff on correct placement and equipment use. • Daily handover sheets now … (AI summary)
Overdue
John Edwards
Concerns: 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.
Response (Response Southwinds Limited): • The organisation stated it closed in December 2017. • The organisation indicated that in this circumstance, no action could be taken. (AI summary)
Overdue
Mavis Reeves
Concerns: 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.
Response (FirstPort Retirement): • Residents were informed of the Careline system's operation during induction, a meeting, and a follow-up letter. • A joint review with Appello Careline was undertaken to ensure correct access … (AI summary)
Responded
Sheila Ross
Concerns: 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.
Overdue
Doris McCarthy
Concerns: 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.
Overdue
Phylliss Letcher
Concerns: The coroner noted the absence of live CCTV monitoring for staircases and communal areas, and raised concerns about the lack of key fob access control for the staircase and an alarm if the stairgate is left open.
Response (Anson Care Services Limited): • The organisation plans to investigate extending existing CCTV coverage to all stairwell levels for retrospective review of falls. • The organisation will seek a different type of latch for … (AI summary)
Responded
Joan Wright
Concerns: 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.
Response (Department of Health): • The Department of Health detailed existing regulations and guidance for controlled drugs, including the Controlled Drugs (Supervision of Management and Use) Regulations 2013 and NICE guidelines. • A statutory … (AI summary)
Responded
Doris Douthwaite
Concerns: The coroner noted that vulnerable residents were left unsupervised in communal areas, with no clear policy for monitoring. Concerns were also raised about an unclear falls risk assessment tool and a lack of investigation into a resident's multiple falls.
Overdue
Anne Roberts
Concerns: The coroner noted gaps in training for staff regarding choking risks for mentally ill patients, issues with information dissemination in hospital records, and challenges in managing choking risks for patients eating in their bedrooms.
Overdue
Beryl Walsh
Concerns: 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.
Response (Beechwood Lodge): • Beechwood Lodge has implemented more robust risk assessments for residents who have experienced falls. • New risk assessments are in place in all care plans concerning safety equipment. • … (AI summary)
Responded
Ronald Houchin
Concerns: 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.
Overdue
Patrick Kelly
Concerns: 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.
Response (Roseberry Care): • The organisation implemented a 'Resident of the Day' procedure for monthly care plan reviews and updates, including resident and/or relative involvement. • A diary record was implemented to track … (AI summary)
Responded
Gloria Mekins
Concerns: 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.
Response (Rossmere Park Care Centre): • The care home implemented a new system to notify staff of DNACPR notices, using blue butterflies on room doors and red notices in resident folders. • The care home … (AI summary)
Overdue
Jeanette Robinson
Concerns: 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.
Response (Cornwall Council): • The Council stated that all Nimbus systems in the community had been replaced with a new mattress system called Elite. • The Council confirmed that all Nimbus stock had … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) confirmed it had no record of the incident as it had not been reported. • The manufacturer, Arjo Huntleigh, logged the … (AI summary)
Responded
Robert Lowe
Concerns: 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.
Overdue
Eileen Pollard
Concerns: The document used for daily call bell checks is pre-populated with 'P' for pass, which risks rooms being missed or failures not being accurately recorded, potentially affecting patient safety.
Overdue
Roy Campbell
Concerns: 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.
Response (Worcestershire Health and Care NHS Trust): • The trust ordered 10 electronic visitor tracking systems for installation across all relevant wards and units. • Environmental check forms were amended, distributed, and staff were instructed to use … (AI summary)
Responded
Edna Davenport
Concerns: 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.
Overdue
Kenneth Clarke
Concerns: 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.
Overdue
Dereck John Chapman
Concerns: 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.
Response (Rossendale Nursing Home): • A Person Centred Software system was purchased, staff were trained, and it was implemented for electronic documentation and daily review. • Walk-around and verbal handovers were established at the … (AI summary)
Responded
Christine Neild
Concerns: 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.
Response (Meade Close Care Home): • Enhanced one-to-one supervision was undertaken with the support worker involved in the incident, and all staff are required to retake a reporting and recording e-learning module. • Resident-specific risk … (AI summary)
Response (Responses from Trafford Council and CQC): • The council provided and reiterated guidance to providers on the safe usage and disposal of PPE, and plans to conduct bi-annual audits to monitor adherence. • The council reiterated … (AI summary)
Responded
Anthony Slack
Concerns: 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.
Response (NHS England and NHS Digital): • North West Ambulance Service (NWAS) established cleaning teams to assist ambulance crews with additional cleaning following patient handovers. • The cleaning service was initially rolled out to eight Emergency … (AI summary)
Response (UK Health Security Agency): • The UK Health Security Agency (formerly Public Health England) established a national team to lead the organisational response to COVID-19 in adult social care settings, coordinating with partners and … (AI summary)
Response (CQC): • The care home implemented improved post-falls management systems, including new observation protocols, monitoring equipment, and staff training on daily record keeping. • The care home confirmed adherence to government … (AI summary)
Response (Greater Manchester Health and Social Care Partnership): • The care home accepted documentation awareness training and updated its Covid-19 admission procedures to require a negative test. • NWAS established cleaning teams at Emergency Departments, including Tameside Hospital, … (AI summary)
Response (Vicarage Care Home): • The care home completed documentation training for all staff and updated its recording policy and proformas. • It implemented regular COVID-19 and infection control training, reviewed its admission policy, … (AI summary)
Responded
Edward Mallaby
Concerns: 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.
Response (Roseberry Care Centres): • Updated policies concerning residents' belongings, admission, and falls management were issued across all care centres, with staff at Alexandra View completing supervision sessions on these by 31st December 2020. … (AI summary)
Responded
Arthur Johnson
Concerns: 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.
Response (Hampshire County Council): • The falls protocol was reviewed and updated in line with current NICE guidance. • The revised protocol directs staff to contact 999 or 111. • Staff will participate in … (AI summary)
Responded
CQC inspection actions(5)
Nottingham City Hospital
The trust must ensure call bell systems are well maintained to keep women and their babies safe.
Must Do
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
St Benedict's Hospice
The service must ensure patients are provided with an appropriate system to call staff in the event of an emergency.
Must 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
Domestic Homicide Reviews(4)
Norfolk — recommendation 7
All services providing care and/or home safety advice to vulnerable adults should include the promotion of the County Council’s assistive technology equipment which includes telephone call centre back-up for emergencies when a family member or carer cannot be contacted. This information must always be included where a pendant alarm is …
All services providing care and/or home …
Gloucestershire — recommendation 17.1.1
Care and nursing home providers should introduce a procedural policy that when a resident presses their assistance bell the responding member of staff should check their needs with them personally, rather than accepting the word of a visitor. Management teams should ensure that all staff are aware of this policy …
Care and nursing home providers
Northumberland — recommendation 9
To consider use of an ‘alert’ system, as recommended in NHCFT’s IMR, to identify patients with complex needs who are frequent attenders to A&E. This is in order to facilitate access to specialist support services and prompt, where necessary, Safeguarding referrals.
Newcastle upon Tyne Hospitals NHS Foundation …
THE NEWCASTLE UPON TYNE …
Northumberland — recommendation 5
To incorporate into the recommended alert system a prompt for Safeguarding referrals, where necessary, in relation to frequent attenders.
Northumbria Healthcare NHS Foundation Trust
NORTHUMBRIA HEALTHCARE NHS FOUNDATION …