Lucy Phelan

I am David Donald William REID, HM Senior Coroner for Worcestershire.

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.”

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.

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:  (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.

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.