Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0209, written 1 Apr 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Apr 2026 |
|---|---|
| Reference | 2026-0209 |
| Deceased | Lucy Phelan |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Worcestershire Acute Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The National Medical Director, NHS England ( england.coroners28@nhs.net );
2. The Chief Executive, NHS Wales ( dsdghsceynhswce@gov.wales ).
1
CORONER
I am David Donald William REID, HM Senior Coroner for Worcestershire.
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act
2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 22 May 2025 I commenced an investigation and opened an inquest into the
death of Lucy Jane PHELAN aged 49. The investigation concluded at the end of the
inquest on 30 March 2026. The conclusion of the inquest was that Ms. Phelan "died
from complications of having taken prescribed medication with a significant amount
of alcohol. Her death was contributed to by neglect."
4
CIRCUMSTANCES OF THE DEATH
On 13.5.25 Lucy Phelan, who lived with Emotionally Unstable Personality Disorder
which led her on occasion to indulge in impulsive risk-taking behaviour, was found
unresponsive at home having vomited after taking various prescribed medications
with a significant amount of alcohol. She was taken by ambulance to the Alexandra
Hospital, Redditch where she was treated for likely aspiration pneumonia, but later
that evening vomited again and soon after that went into cardiopulmonary arrest.
Alarms notifying staff at the hospital of her collapse went unheeded for some nine
minutes. When an emergency was called, doctors were unable to resuscitate her,
and she was confirmed deceased shortly after midnight on 14.5.25.
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to
concern. In my opinion there is a risk that future deaths will occur unless action is
taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
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.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
both have the power to take such action by reviewing the use of the “latching”
facility in hospitals in England and Wales.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 27th May 2026. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting
out the timetable for action. Otherwise you must explain why no action is
proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following:
( Ms. Phelan’s mother );
N ( Ms. Phelan’s father );
N ( Ms. Phelan’s sister ).
I have also sent it to:
The Chief Executive, Worcestershire Acute Hospitals NHS Trust
who may find it useful or of interest.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or
summary form. He may send a copy of this report to any person who he believes
may find it useful or of interest. You may make representations to me, the coroner,
at the time of your response, about the release or the publication of your response
by the Chief Coroner.
9
1st April 2026
2
David REID
HM Senior Coroner for Worcestershire
3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mr David Donald William Ried
HM Senior Coroner
Worcestershire Coroner’s Court
The Civic
Martins Way
Stourport-on-Severn
Worcestershire
DY13 8UN
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
2nd June 2026
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Lucy Jane Phelan who
died on 14 May 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1 April
2026 concerning the death of Lucy Jane Phelan on 14 May 2025. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Lucy’s family and loved ones. NHS England is keen to assure
the family and yourself that the concerns raised about Lucy’s care have been listened
to and reflected upon.
Your Report raises concerns around:
•
‘Alarm fatigue’ 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 ‘latching’ facilities on monitoring equipment is likely to contribute to
the phenomenon of ‘alarm fatigue’. This has been recognised 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.
•
NHS England’s National Patient Safety Team have advised that ‘alarm fatigue’ is a
recognised phenomenon and the function ‘alarm latching’ is a setting that requires any
triggered alarm to be manually acknowledged and resolved by a member of staff.
There are however, other limitations relating to any secondary triggered alarm that
may tailor use of this function. The suggestion that ‘the equipment manufacturer no
longer recommends the use of alarm latching functionality on the Emergency
Department monitors’ is currently subject to further investigation as such information
would need to be officially communicated to all users and be part of the medical device
manual and Instructions for Use (IfU) documents.
The NHS England National Patient Safety Team are engaging with the regulator of
medical devices, the Medicines and Healthcare products Regulatory Agency (MHRA),
to explore whether this is the manufacturer position and whether these requirements
have been met.
The MHRA are the correct authority to advise on concerns regarding medical devices
with alarm latching capabilities healthcare organisations. The NHS England National
Patient Safety team will continue to engage with the MHRA to understand how latching
functionality is best managed in the clinical environment. The MHRA will be coming
back to us once they have gathered further information from the manufacturer
regarding this specific case.
Midlands regional colleagues have advised that this case will be shared with the
relevant Integrated Care Board and with regional nursing colleagues for information
and will suggest the possibility of sharing the learning with Trust Patient Safety
Specialists. We have also been advised that learning will also be shared at the
Mortality Forum due to be held in June 2026.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of Lucy,
are shared across the NHS at both a national and regional level and helps us to pay
close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Director of Patient Safety
NHS England
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