Recurring concern

Unreliable medication management in care homes

First to latest report 28 Feb 2014 — 30 Jan 2026

Reports that mention this concern
11
Times this concern has been raised
15
Stated actions linked to this concern
13

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.

What is 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 and published responses 11 reports

See individual reports that have raised this concern, and the actions taken in response

  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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026