Recurance · prevention of future deaths reports
Pre-inquest brief
Unaccounted controlled drugs in care home administration
The earlier warning
Derrick Rivers · 10 Mar 2014 · Lisa Hashmi, Manchester (North)
“not all CQC Outcomes were considered at the last inspection, purportedly because they did not have anyone available to inspect and review the drugs administration system at the material time”
judiciary.uk/prevention-of-future-death-reports/derrick-rivers
What was promised
Stated action 1 · response to Stephen Coulson (27 Oct 2017) · stated 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.”
What recurred
- 27 Oct 2017 · Stephen Coulson · Rashid Sohail · Closely related · confidence 0.80 (moderate)
- 25 Feb 2020 · Elaine Renshaw · Alison Mutch · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Stephen Coulson · 27 Oct 2017
“the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs”
Later · Elaine Renshaw · 25 Feb 2020
“processes had been such that it was not easily identified that drugs were not accounted for e.g. Stock sheets were inaccurate”
What happened next
No web check of the stated actions has been published for this chain.