“While in the resuscitation bay within the Emergency Department at the Alexandra Hospital…”
Dated 1 Apr 2026, from the coroner for Worcestershire. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 27 May 2026. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated1 Apr 2026
- Deadline27 May 2026
- Published on judiciary.uk13 Apr 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Worcestershire Acute Hospitals NHS TrustNamed in the report as “Worcestershire Acute Hospital NHS Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
– While in the resuscitation bay within the Emergency Department at the Alexandra Hospital, Redditch, Ms. Phelan was attached to equipment which monitored her physical observations. These observations are visible on a screen at the patient’s bedside and on a screen at the main nursing station. If a patient’s observations rise or fall outside acceptable parameters, the equipment generates both an audible alarm and a visual alarm ( red – higher priority; yellow – lower priority ) on each monitor. The monitoring equipment has a facility known as “latching” which, if activated, means: 1 (a) an alarm will continue to be displayed and sounded even after the conditions which generated it have ended, until it is acknowledged on the monitor, meaning that any alarm for a new or different indication cannot be distinguished audibly; and (b) if the alarm is not acknowledged on the monitor, and the same alarm condition occurs again, this new alarm is not listed in the alarm review or audit log as a new alarm. The inquest heard evidence that “alarm fatigue” is a recognized phenomenon, and that in a busy environment like a hospital’s Emergency Department, particularly when patient numbers are high, staff find it increasingly difficult to react and respond to the many different types of alarm in use. The use of the “latching” facility on monitoring equipment is likely to contribute to this phenomenon ; this has been recognized by the equipment manufacturer which no longer recommends its use on Emergency Department monitors, and by Worcestershire Acute Hospitals NHS Trust who have switched it off on monitors in its Emergency Departments. It is not known whether, and to what extent, the “latching” facility remains in use in Emergency Departments in other hospitals in England and Wales.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2026-0209
- Added to Minute Book
- 8 Oct 2026
- Reuse
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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