The National Health Service has criticized a hospital for giving its elderly patients a tambourine to call nurses when in need instead of electronic alarms.
And in case that broke, a pair of maracas was also supplied as a back up.
One man visiting his mother put the system to the test by rattling the tambourine for 16 minutes - but failed to attract the staff's attention.
The hospital was forced to apologise after an NHS watchdog described the policy as "unacceptable" and criticised it for failing to install a proper alarm system.
The farcical arrangement was put in place at Cardiff Royal Infirmary after more than 30 elderly patients in the west wing complained that they were "too scared" to use the day room in case staff did not hear their calls for help.
The room is almost 40 yards from the nurses' base at the Victorian hospital, which is notorious for its long corridors and has even been used to film episodes of Doctor Who.
"This is totally unacceptable and the health board must address this as a matter of concern," the Daily Mail quoted Steve Allen, chief officer of Cardiff and Vale of Glamorgan Community Health Council, as saying.
Ruth Walker, executive director of nursing for Cardiff and Vale University Health Board, yesterday apologised.
She said: "A hand-bell had previously been provided but was deemed too heavy and cumbersome for frailer patients and staff looked for an alternative.
"Sadly the solution, while well-intentioned, was not appropriate.
"A lightweight hand-bell will now be sourced as a matter of urgency and patients will be accompanied while using the dayroom in the meantime.
"The care and dignity of all our patients is vitally important to everyone at the health board and we sincerely apologise for any distress this has caused," she added.