Inadequate double check in controlled drug audit
NHS England received 2 coroners' reports about this hazard between 27 Oct 2017 and 4 Oct 2019.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs”
Original on judiciary.uk ↗ NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The Trust has now implemented an extensive action plan, they have: e Updated the Trust Controlled Drug Policy to include reference to the Opiate Patch Monitoring Form to ensure that the clinical team are aware of the opiate patches worn and administration date.”
“The policy was updated in November 2017 to include reference to an opioid patch monitoring form. The use of the form should minimise the risk of a similar incident experienced by Mr [name redacted] being repeated. The trust managers have informed the Commission that they plan to audit implementation of the form. We will monitor this through our quarterly engagement meetings and subsequently consider this at the next inspection, which is likely to take place between October and December 2018.”
Stated timescale: between October and December 2018
- 1 year 11 months laterClosely relatedConfidence 0.92 · higha different coroner
“The audit checking of controlled drugs by The Boots Company PLC is not robust in that there is no double check in place in relation to the audit checking procedure followed by Boots”
Original on judiciary.uk ↗ Repeated from the earlier report:auditcontrolleddrugsplace
The most recent report. A response may not be due or published yet.
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2017 → 2019Michael Lobban1 year 11 months after Stephen Coulson · different coronerClosely relatedConfidence 0.92 · high
Closely relatedConfidence 0.92 · highBoth reports highlight weaknesses in the audit and checking procedures for controlled drugs, specifically the lack of a robust double‑check system.
Stephen Coulson · 27 Oct 2017
“the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs”
Original on judiciary.uk ↗ Michael Lobban · 4 Oct 2019
“The audit checking of controlled drugs by The Boots Company PLC is not robust in that there is no double check in place in relation to the audit checking procedure followed by Boots”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The policy was updated in November 2017 to include reference to an opioid patch monitoring form. The use of the form should minimise the risk of a similar incident experienced by Mr [name redacted] being repeated. The trust managers have informed the Commission that they plan to audit implementation of the form. We will monitor this through our quarterly engagement meetings and subsequently consider this at the next inspection, which is likely to take place between October and December 2018.”
Stated action
“The Trust has now implemented an extensive action plan, they have: e Updated the Trust Controlled Drug Policy to include reference to the Opiate Patch Monitoring Form to ensure that the clinical team are aware of the opiate patches worn and administration date.”
Stated action · timescale: between October and December 2018
“The policy was updated in November 2017 to include reference to an opioid patch monitoring form. The use of the form should minimise the risk of a similar incident experienced by Mr [name redacted] being repeated. The trust managers have informed the Commission that they plan to audit implementation of the form. We will monitor this through our quarterly engagement meetings and subsequently consider this at the next inspection, which is likely to take place between October and December 2018.”
No published response from NHS England was found for this report. It is the most recent report, so a response may not be due or published yet.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2017 → 2019 | 0.72 | 0.20 | Closely related · 0.92 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.