Steven Kirkham

FAO: Ms N J Mundy 
HM Coroner for South Yorkshire 
Coroner’s Court 
Crown Court 
College Road 
Doncaster 
DN1 3HS 

Your Ref: 
Date:

12 November 2021 

Dear Sirs 

Inquest Touching the Death of Steve Paul Kirkham (the “Deceased”) 
Date of Death: 30 April 2019 
Inquest Date: 18 August 2021 
Our Client: Intastop Limited 

As you are aware, we are instructed to represent Intastop Limited. 

Firstly, may we thank HM Coroner for her patience in awaiting our client’s response to 
the Prevention of Future Deaths Report dated 18 August 2021. The extensions granted 
have enabled a  response to be prepared which we hope HM Coroner finds detailed 
and comprehensive. 

Circumstances of the Death & Concerns Raised 

Our client understands that the Deceased was a resident in a private room (room 17) 
of Osprey Ward, Swallownest Court, Sheffield. The door to the en-suite in the room 
had been fitted with a device by our client in 2013 which was designed to sound an 
alarm should any weight be applied to the door, thereby altering staff.  

. It is 
On 2 April 2019, the Deceased
suggested that no alarm  sounded albeit evidence is contradictory with 
, 
Clinical Supervisor employed by Yorkshire Ambulance Service NHS Trust, stating that 
he was informed by staff at Swallownest Court that they were alerted by a room alarm 
activated  from the  top of the toilet  door. Our client attended on  3  April  2019 and 
confirmed the door alarm was in proper working order. However, it was identified and 
is accepted that there was a “blind spot” between the door, frame and domed cap near 
to the hinge area.  

HM Coroner has identified the following matters of concern: 

1. The presence of a “blind spot” on the door mechanism;
2. The potential for the door mechanism involved in this incident to be used in
other places where vulnerable people are housed with the users unaware of
the potential danger; and

 3. The absence of information from our client in respect of action taken to rectify

the “blind spot” area.

Response to Concerns 

Firstly, our client wishes to express its apology for the absence of information available 
at the Inquest about action taken in response to this incident. Unfortunately, our client 
was not an Interested Person and had no knowledge of the Inquest proceedings.  

HM Coroner may be assured that our client undertook a comprehensive investigation 
in  response to  this  incident,  the  findings of which  were  shared  with  Rotherham, 
Doncaster and South Humber NHS Trust on 9 April 2019. A copy is enclosed for HM 
Coroner’s attention.  

By way of summary: 

• Our client attended at Swallownest Court on 3 April 2019 in order to check the
operation of the Intastop door top alarm on the en-suite of Bedroom 17 where
the incident had occurred.

• Upon arrival,  our client was  also  asked to check as  many  of the other door
alarms  as possible (excluding those in occupation) and produce a report on
their operation, in particular looking at the installation and tamper delay.

• The Schedule of checks undertaken is  detailed  within the  Door Top  Alarm
(Maintenance)  Check  Sheet  which  is  again  enclosed  for  HM  Coroner’s
attention. All the alarms  checked operated as intended, including that on door
17.

. Unfortunately it 
The Intastop door top alarm is designed to reduce the risk of
is  impossible  to  completely  eliminate  any  chance  of 
  and  this  has  been 
communicated to all  users of the product. However, in response to this tragic event, 
and in an effort to prevent any future death, our client has undertaken the following 
actions:  

• The alarm  design was  immediately  amended to include a  mechanical  fixing
 further. All

between the hinge and the alarm so as to reduce the risk of 
NHS trusts have made aware of the re-designed door alarm that is available.

• All trusts were reminded that products installed by Intastop must be maintained
as  per  Intastop’s  fitting instructions and/or  the  operation and  maintenance
manual.  Trusts  were  also  made  aware  of  the  planned  preventative
maintenance that was available through Intastop.

• As  it  was  apparent  from  the  post  incident  investigation  that  there  was
inconsistency when re-setting the door alarms,  staff at  Swallowdale were re-
trained on how and when to check the alarms as detailed in the operation and
maintenance manual.

• The alarm has since been further re-designed to reduce the risk of

 even 

further and this is currently being live trialled at another NHS Trust.

 HM Coroner can be confident that Intastop continuously looks to improve its existing 
product range and/or introduce new products to ensure it is meeting the needs of its 
customer and reducing 
 risk as  much as  possible. Intastop has  always,  and 
continues to  work closely  and  actively  with  Trusts as  regards communicating  and 
trialling new product designs.  

Intastop recognises that it is crucial the construction, design and health industries work 
together to create safer environments for patients and HM Coroner may be assured of 
Intastop’s commitment to knowledge raising across the industry. In this regard, one of 
Intastop’s employees, 
,  Director of Business Development, sits  on the 
innovation  and  testing  sub-committee  of  the  Design  in  Mental  Health  Network 
(DIMHN). In conjunction with BRE,  in May  2021, the DIMHN launched a  world -fist 
testing scheme for products used in mental health care facilities. The scheme offers 
comprehensive testing  guidance  for materials,  fixtures and  hardware  used  within 
mental  healthcare  facilities,  to  include  identifying “blind-spots” and  how  they  are 
managed,  thereby offering vulnerable patients more protection from 
 than 
ever before.  

We  trust  the  contents  of  this  correspondence  adequately satisfy  HM  Coroner’s 
concerns, however, should any further information be required, please do not hesitate 
 who will in turn liaise  with our client who is happy to 
to contact our 
assist in any way.  

Yours faithfully 

Keoghs LLP 

Enclosures: 

• Site Visit Report dated 05.04.2019
• Door Top Alarm Maintenance Check Sheet

 April 2019 Swallownest  Osprey Ward Site 
Visit  

Attendees 
Intastop 

RDASH 

- Maintenance 

(via telephone) 

Summary of Visit 
Intastop were called to site on 3rd April 2019 to check the operation of a door top alarm on room 17 
Osprey ward, Swallownest, after an incident the night before. The alarm was checked and 
operational.  The 
within appendices) this was referred to by the trust as a ‘blind spot’. We have identified some 
recommendations at the end of this document. 

 point was found to be between the door, frame and domed cap (see photo 

14 of the 18 alarms on the site were also inspected (4 rooms had patients in them) and the 
maintenance report is attached within the report. 

Contents 

Attendees ........................................................................................................................ 1 

Summary of Visit ............................................................................................................... 1 

Background ...................................................................................................................... 2 

Site Survey Report ............................................................................................................. 2 

Conclusion ....................................................................................................................... 5 

Trust Recommendation ...................................................................................................... 5 

Appendices ...................................................................................................................... 6 

1 

 
 
 
 
  
 
 
  
 
 
 
 
 Background 
On 3rd April 2019 we received a call to the Intastop office which was taken by 

 from 

, RDASH, at St Catherine’s Hospital, Doncaster that a serious incident had occurred 

in room 17 Osprey Ward, at their Swallownest site and that we were required to attend site 
immediately to test the function of the door top alarm on the en-suite door of the room in question. 
This was reported to myself by 
our testing kit just after midday. 

 and I went to the site with 

 immediately and 

The Door Top Alarms were supplied in 2013. 

Site Survey Report 
, 
, we spoke to 
On reaching site and being introduced to the Maintenance Officer 
Estates Manager for the trust who spoke to us on 
phone asking if we could check as many of 
the alarms as possible for operation and specifically produce a report on their operation by close of 
 had 
business and specifically room 17 where the incident happened. He also commented that 
checked all the alarms and that most had intermittent faults i.e. they may work in one position, but 
not another for example bedroom 17.  It was claimed it intermittently sounded in the centre middle 
and end and 
 had checked all Osprey and Sandpiper Wards and that he had found the same 
issues on all the alarms and also that the time delay between triggering the alarm and the alarm 
sounding was 20 seconds not 10 as intended. 

 also said he would like to organise a full PPM inspection and that the incident had occurred by 
 with the patients cord out of their pyjamas between the door, frame and domed 

forming a
cap (see photo within appendices) this was referred to by the trust as a ‘blind spot’. 

See below the schedule issued to Intastop on site that we have replicated and typed up on the Door 
Top Alarm (Maintenance) Check Sheet attached. 

2 

 
 
 
 
  the Unit Director then escorted us to room 17 with two colleagues and 

, (the 

names of which I did not catch).
fatality. 

explained what had happened and that there had had been a 

 requested that we test the operation of the Intastop door top alarm on the en-suite of 

Bedroom 17 where the incident occurred the previous night and then asked us to check: 

1)  The installation and the tamper delay 
2)  The operation of the alarms – it was thought they were not operating as they should 
3)  To check as many alarms as possible 

The door top alarm alerted the staff attack system, sounded at the staff attack station and re-set as 
intended, we tested as per our procedures using a magnet to identify the operating cycle through 
the led lighting system i.e. green: working, amber: tamper loop  delay, red: alarmed. The alarm 
sounded at 6.75 seconds. 

The unit had power and sounded the alarm at 6.75 second. The LED went to red with no tamper 
delay LED light (amber), this could mean a loose or unconnected wire in the tamper loop or the 
alarm was not indicting it was following the tamper setting. This needs further investigation, but 
does not affect the alarm working as intended. 

The 
appendices) this was referred to by the trust as a ‘blind spot’ 

 point was found  to be between the door, frame and domed cap (see photo within 

After which she asked us to check as many as possible and then review the site visit with her at the 
end of those checks. 

3 

 
 
 
 
 We then checked and recorded all of the alarms identified in the schedule as well as accessing the 
loft space and checking what setting the control box for room 17 was set at it was set at 5 seconds.  

We then carried out checks on all the alarms and their operation and the intermittent fault 
identified by 
earlier testing,
when they were depressed so soon.  

 was proven to be incorrect and all the alarms operated as intended. During the 

 had not allowed the system to re-set and therefore they would not alarm again 

The alarms in rooms 1, 2, 7, 15 could not be checked as they had patients in them. – we requested 
that we did not check alarms in front of patients, so these rooms were not checked.  

On finishing our site check on Osprey Ward we sat down and reviewed with
and the trust director (whose name I did not get), we were asked some operational questions on the 
alarm which we answered and requested to produce a brief report, as well as organising a thorough 
check of all sites to be arranged with 

 and her team 

 asap. 

 concluded that she would have to put a nationwide alert to all trusts regarding the

risk when used in conjunction with the alarms.  

We sent a preliminary report as requested on Wednesday, 03-04-2019 (see appendices). 

4 

 
 
 
 
 
 
 
 Conclusion 
The 14 alarms were all functioning as required including door 17.  

The door top alarm is designed to reduce the risk of 
eliminate completely any chance of 

.  

, unfortunately it is impossible to 

Trust Recommendation 

• 
• 

Identify and rectify the problem found  with tamper loop on alarm 17. 
Inspect all the sites at Scunthorpe, Swallownest and Doncaster and check the operations of 
the alarms. 

•  Offer more training for the staff on the operation and testing using the magnets. 
• 

Inspect the 4 rooms we were unable to access on 3.4.19. 

5 

 
 
 
 
 
 
 
 Appendices 
Email to trust. 

Wed 03/04/2019 18:18 

Hi 

Firstly, we wish the visit to site today had been under different circumstances, but hope we answered 
the questions you had today clearly. 

This is a brief report on the operation of the Intastop door top alarms installed on the Osprey Ward at 
the Swallow Nest Site with specific detail on Bedroom 17 where an incident occurred the previous 
night. We were asked to check: 

4)  The installation and the tamper delay 
5)  The operation of the alarms – it was thought they were not operating as they should 
6)  To check as many alarms as possible 

1)  The installation of the alarm 

The installation of the alarm was correct, the hinge could have been slightly more elevated as per the 
image below and was slightly offset on the door. 

6 

 
 
 
 
 
 
 
 
 2)  The operation of the alarms in the Osprey Ward 

We tested the timing delay and it was between 5 and 6 seconds on all the alarms in the osprey ward. 
The timing setting on the control box in the loft space adjacent to bedroom 17 was set at 5 seconds. 
The operation discrepancy highlighted i.e. intermittent faults, was caused by not allowing the alarms 
to re-set before testing. 

We checked the alarm functions at the centre and either end and they operated correctly i.e. 
followed the anti-tamper loop then set off. The only alarm that did not follow the tamper loop was 
bedroom 17 meaning it alarms immediately. This is probably a wiring fault in the hinge or control 
box. 

We recommend we check thoroughly all the alarms and re-set the sensors as continuous use of the 
doors means they can fail, but they have not on Osprey. This I estimate will take 1-2 days, I think 
there are 40 alarms on this particular batch of installs that occurred in 2013. Also that you visit us 
here at Intastop to inspect our testing protocol prior to dispatch. 

7 

 
 
 
 
 
 
 
 
 3)  We checked all of Osprey. 

Please contact me direct should you have any more questions and after the full site service inspection 
we can provide certificates of conformity. 

Best Regards 

  | Managing  Director  

Holly Street, Kelham Street Industrial Estate, Doncaster, DN1 3TR, United Kingdom 

www.intastop.com 

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8 

 
 
 
 
 
 
  
 
 
 
 
 
 
 Picture 1 

‘Blind Spot’ 

9