Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate double check in controlled drug audit
The earlier warning
Stephen Coulson · 27 Oct 2017 · Rashid Sohail, Manchester (City)
“the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs”
judiciary.uk/prevention-of-future-death-reports/stephen-coulson
What was promised
Stated action 1 · response to Stephen Coulson (27 Oct 2017) · stated timescale: none stated
“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 2 · 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
- 4 Oct 2019 · Michael Lobban · Russell Caller · Closely related · confidence 0.92 (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 · 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”
What happened next
No web check of the stated actions has been published for this chain.