Recurring concern

Unreliable medication management in care homes

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First reported 28 Feb 2014•Latest report 30 Jan 2026

Definition

What this concern includes

Includes care-home failures in medication governance and management, including medication policies and procedures, prescribing or administration controls, access restrictions, documentation, checking, monitoring and escalation where these directly concern safe medication use for residents.

Not included

  • Excludes medication failures outside care-home resident medication management unless the assertion explicitly concerns the same care-home process.
  • Excludes generic staffing, training, communication or record-keeping deficiencies unless they directly impair safe medication management in a care home.
  • Excludes medication supply, prescribing, dispensing or administration concerns governed by a more specific established medication-safety parent when the narrower concern is the better boundary.
  • Excludes clinical treatment or monitoring failures unrelated to medication management.
Reports
11

Distinct published reports

Individual concerns
15

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
13

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission3
700 Club1
Alexandra Court - Cleveleys1
Cann House Care Home1
Care4u Health Care Limited1
Care UK1
Cherish Home Care Ltd1
Department of Health and Social Care1
Four Seasons Health Care Group1
Hc-One Limited1
Office of the Chief Coroner1
Passmonds House Care Home1
Premiere Health Limited1
Rochdale Borough Council1
South Tyneside Borough Council1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. County Durham and Darlington

    AI-generated summary

    Richard Philip WHITE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Richard White was a resident at Hope House who took an overdose of cyclizine and zopiclone on 9 June 2013 and subsequently died from cyclizine toxicity. The concerns were that Hope House’s medication policy was not made known to the prescriber or others involved, was not set out in a protocol or policy statement, and that no such document was available.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to make the medication administration and holding policy known to prescribers

    Wider context from the report

    “1) That the policy of Hope House with regard to the administration and holding by staff of medication was not made known to ████████ when she wrote the prescriptions; 2) That the policy was not provided in a protocol, or policy statement, to ████████, or indeed, ████████ and ████████ 3) That no such protocol or policy statement was available. ”

    Source location

    Richard Philip WHITE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026