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: (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.