Recurring concern

Unreliable support for patients taking prescribed medication

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First reported 19 Sep 2013•Latest report 2 Apr 2026

Definition

What this concern includes

Includes commissioned or care-plan medication support, supervised taking, ingestion checks, continuity of assistance and reassessment of support when insight, capacity or adherence is at risk.

Not included

Excludes ordinary administration of medication by clinicians or nurses when the patient does not require a distinct medication-taking support arrangement; those belong to medication administration.
Excludes prescribing, dispensing, supply, storage, reconciliation and medication review.
Excludes risk assessments or protective plans that do not directly provide medication-taking support.
Excludes treatment of medication effects or toxicity after medication was taken.

Reports: 9
Individual concerns: 9
Date range: 2013–2026
Stated actions: 17

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Wife of the deceased2

Care Quality Commission1

Central and North West London NHS Foundation Trust1

Daughter of the deceased1

Dorset Healthcare University NHS Foundation Trust1

East London NHS Foundation Trust1

Gloucestershire Social Services1

Home Office1

Langley Health Centre1

Mitie1

Mitie Care And Custody Limited1

Multi-Care Community Services Suffolk1

Norfolk and Suffolk NHS Foundation Trust1

Oakside Surgery1

Oxford Health NHS Foundation Trust1

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.

2 Apr2026
Suffolk
Concerns raised1
1. Inadequate support for medication management
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review, update and communicate medication-management policies, including compliance and escalation requirements.
  Stated by Multi-Care Community Services Suffolk LtdStated completed
2. Action
  Complete mandatory medication-administration refresher training and competency assessments for care staff.
  Stated by Multi-Care Community Services Suffolk LtdStated completed
3. Action
  Conduct ongoing medication safety monitoring through spot checks, audits, observations, supervision and competency reassessment.
  Stated by Multi-Care Community Services Suffolk LtdStated completed
AI-generated summary

Peter PETTITT · 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

Peter PETTITT, aged 86, died on 11 September 2023 after developing sepsis due to bronchopneumonia and acute pyelonephritis. The report raised concerns about inadequate care records, gaps in medication and catheter support, and insufficiently assured training and management arrangements for the commissioned care provided to him.

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
Inadequate support for medication management
Wider context from the report
“In addition to poor record keeping, evidence heard during the Inquest raised concerns as to the adequacy of the support provided to Mr. PETTITT in the management of his medication. Stockpiles of medication were found at the residence clearly reflecting a lack of compliance by Mr. PETTITT in his medication regimen; support to Mr. PETTITT in medication management was a service Multi-Care Community Services Suffolk were commissioned to provide. No formal concern in relation to non-compliance with medication was raised by Multi-Care Community Services Suffolk with either the commissioning authority (Suffolk County Council), or Mr. PETTITT’s General Practice. ”
Source location
Peter PETTITT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review, update and communicate medication-management policies, including compliance and escalation requirements.

Verbatim wording from the response
“Multi-Care reviewed and updated all medication management policies and procedures following the incident. These revised policies were communicated to all staff, with clear expectations regarding compliance and escalation procedures.”

Source location
Response from Multi-Care Community Services Suffolk
Page 2 · response
Published 10 April 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Complete mandatory medication-administration refresher training and competency assessments for care staff.

Verbatim wording from the response
“All care staff have completed mandatory refresher training and competency assessments relating to medication administration. The training includes:”

Source location
Response from Multi-Care Community Services Suffolk
Page 2 · response
Published 10 April 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct ongoing medication safety monitoring through spot checks, audits, observations, supervision and competency reassessment.

Verbatim wording from the response
“To ensure continued compliance, Multi-Care now conducts:”

Source location
Response from Multi-Care Community Services Suffolk
Page 2 · response
Published 10 April 2026
Open published response
6 Jan2026
Bedfordshire and Luton
Concerns raised1
1. Withdrawal of medication administration support despite known lack of insight and need for medication compliance
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mohammed Ashraful Islam CHOUDHURY · 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

Mohammed Ashraful Islam CHOUDHURY, aged 26, died at hospital on 11 January 2023 after being attacked and stabbed by another resident at his supported accommodation. The concerns included inadequate management of the other resident’s known risks, lack of a multidisciplinary plan after he stopped taking medication, and withdrawal of medication support without checking with his GP that prescriptions were being obtained.

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
Withdrawal of medication administration support despite known lack of insight and need for medication compliance
Wider context from the report
“(i) The risks identified in respect of ████████ on his discharge from his second hospital admission in August 2020, which included the fact that his paranoid schizophrenia (unusually) was associated with violent behaviour and that he lacked insight into his mental illness, were not adequately addressed by his mental health provider. This was of particular concern when he became non-concordant with his anti-psychotic depot medication from mid-September 2022. (ii) There was no MDT plan to address the significant development of ████████ non-concordance with his anti-psychotic depot medication from mid-September 2022. (iii) Despite knowing that ████████ lacked insight into his mental illness and of the need to ensure that he remained compliant with all medication, the support provided to him with medication administration, in addition to his depot, was withdrawn without there being any checks made with his GP as to whether he was remaining complaint with this medication (which he was not). ”
Source location
Mohammed Ashraful Islam CHOUDHURY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
5 Jun2025
Oxfordshire
Concerns raised1
1. Failure to supervise medication taking as specifically instructed
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review the CRHTT medications management process, standard operating procedure and staff orientation resources to clarify responsibilities and decision-making.
  Stated by The TrustStated in progress
2. Action
  Develop a medications-management flowchart and assessment pro-forma to support administration-route decisions and efficacy assessment.
  Stated by The TrustStated completed
3. Action
  Adopt the new medications-management flowchart and assessment pro-forma for use by the CRHTT.
  Stated by The TrustStated planned
AI-generated summary

Cain Alex River Donald · 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

Cain Alex River Donald died by hanging on 29 July 2022 after being discharged from Ashurst PICU directly into the community on 19 July 2022. The principal concerns were deficiencies in discharge planning and communication with his family and Probation Services, and failure by the Crisis Home Treatment Team to supervise medication administration and escalate concerns about compliance.

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 supervise medication taking as specifically instructed
Wider context from the report
“Post-discharge management of risk arising from medication compliance and multi-disciplinary team review. (3) Evidence suggested that during the period immediately prior to Mr Donald's death, staff of the CRHTT did not implement specific instructions to supervise Mr Donald taking his medication. By 24 July 2022, a decision had been made that Mr Donald should be supervised when taking his medication, but this direction was not adhered to in the following days. Escalation of this issue did not occur. There was no evidence of steps taken by the Trust since Mr Donald's death by way of training or guidance to CRHTT staff to address these issues. My conclusion was that had supervision and escalation taken place, it is possible this may have prevented a deterioration in Mr Donald's mental health which led to his death. ”
Source location
Cain Alex River Donald · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the CRHTT medications management process, standard operating procedure and staff orientation resources to clarify responsibilities and decision-making.

Verbatim wording from the response
“Lastly, the CRHTT is reviewing their medications management process in light of the inquest and your findings. The CRHTT clinical nurse lead is leading this work and met our Associate Director of Nursing in May 2025 in order to discuss your findings. The CRHTT has reviewed”

Source location
Response from Oxford Health NHS Foundation Trust
Page 2 · response
Published 17 June 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a medications-management flowchart and assessment pro-forma to support administration-route decisions and efficacy assessment.

Verbatim wording from the response
“both its standard operating procedure and local staff orientation resources to ensure clarity regarding how and who is responsible for making decisions and undertaking actions in relation to all aspects of medications management. In summary, there are four broad scenarios for medications management: clinician administers medications, patient takes responsibility for self-administration of medications, a trusted person is involved, or prompting medications. The team has (since the inquest) developed two documents to assist with decision making and assessment of efficacy of medications. The first is a flow-chart directed at achieving the right route for each patient how medications are administered; the second is an assessment pro-forma to measure the efficacy of medications.”

Source location
Response from Oxford Health NHS Foundation Trust
Page 3 · response
Published 17 June 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Adopt the new medications-management flowchart and assessment pro-forma for use by the CRHTT.

Verbatim wording from the response
“both its standard operating procedure and local staff orientation resources to ensure clarity regarding how and who is responsible for making decisions and undertaking actions in relation to all aspects of medications management. In summary, there are four broad scenarios for medications management: clinician administers medications, patient takes responsibility for self-administration of medications, a trusted person is involved, or prompting medications. The team has (since the inquest) developed two documents to assist with decision making and assessment of efficacy of medications. The first is a flow-chart directed at achieving the right route for each patient how medications are administered; the second is an assessment pro-forma to measure the efficacy of medications.”

Source location
Response from Oxford Health NHS Foundation Trust
Page 3 · response
Published 17 June 2025
Open published response
28 Aug2019
London (West)
Concerns raised1
1. Inconsistent checks that detainees swallow issued medication
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Amir Siman-Tov · 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

Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.

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
Inconsistent checks that detainees swallow issued medication
Wider context from the report
“5. Mr Siman-Tov expressed that he might save his medication and take as an overdose. There was conflicting evidence as to the rigour of the checks to ensure detainees had swallowed issued medicine at the time of dispensing and the nurses who gave evidence described different practices of observation. Mr Siman-Tov was able to collect sufficient codeine ultimately to be able to end his life. This lack of consistency of checks puts detainee’s at risk. ”
Source location
Amir Siman-Tov · Prevention of Future Deaths report
Page 3 · concerns
Open source report
19 Apr2018
Dorset
Concerns raised1
1. Lack of a policy for supervising all prescribed medication when medication access is identified as a patient risk
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Amanda Mary Spark · 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

Amanda Mary Spark, who suffered with depression, was found collapsed and unresponsive at her home on 3 September 2017 and died from an overdose of prescribed medication. The inquest concluded that her death was suicide. The principal concern was that supervision applied to her mental health medication did not also cover prescribed physical health medication, and that there was no clear policy or communication process addressing this.

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
Lack of a policy for supervising all prescribed medication when medication access is identified as a patient risk
Wider context from the report
“iii. Evidence was given that although the GP is written to when there is a change in regime regarding the mental health medication, there is no action taken in relation to the physical health medication. This may be a matter for the GP to resolve but if a patient’s access to medication is to be immediately changed by DHUFT employees, this should be addressed in relation to all medication not just mental health medication. iv. I heard evidence from the Psychiatric Liaison Team Lead and the Crisis Team Lead that there does not appear to be a policy in place at the Trust to deal with the communication of the supervision of physical health medication. If there is such a policy, they advised me that they are not aware of it. v. Once the access to medication has been identified as a risk to a patient and there is a need for the taking of it to be supervised, access to, and the taking of, all medication, not just mental health medication, should be supervised. 2. I have concerns with regard to the following: i. That there is no policy in place in relation to the supervision of prescribed physical health medication when a decision has been made to supervise the administration of prescribed mental health mediation. I would therefore request that DHUFT review their policies regarding the supervision of all medication a patient is prescribed and when and how to alert GPs, or other treating practitioners, regarding changes to mediation regimes and supervision. ii. If there is already such a policy in place to deal with both physical health and mental health mediation, then I would request that refresher training is undertaken to ensure all staff are made aware of the policy and the procedures to be adapted in such circumstances. ”
Source location
Amanda Mary Spark · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 Jul2014
Norfolk
Concerns raised1
1. Unavailability of medication-taking advice when the prescribing doctor is absent
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Graeme Alexander Kidd · 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

Graeme Alexander Kidd was found hanging at home on 6 March 2014 and died in hospital on 7 March 2014. The report identified concerns about locum doctors’ access to records and knowledge of local mental health services, delays in GP referrals, the lack of medication advice when the prescribing doctor was unavailable, and the delayed implementation of an action plan addressing these matters.

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
Unavailability of medication-taking advice when the prescribing doctor is absent
Wider context from the report
“(4) In the absence of the prescribing Doctor, no-one was available to advise the patient as to how the medication was to be taken. ”
Source location
Graeme Alexander Kidd · Prevention of Future Deaths report
Page 2 · concerns
Open source report
7 May2014
Inner North London
Concerns raised1
1. Failure to administer PD medication in accordance with patients’ usual regimens
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Disseminate reminders about timely Parkinson’s medication through the Quality and Safety newsletter, linked resources, video, and the Clinical Practice Facilitators forum.
  Stated by University College London Hospitals NHS Foundation TrustStated planned
AI-generated summary

Peter John BROOKES · 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

Peter John Brookes was admitted to hospital after complications following catheterisation and later experienced problems with the administration of his Parkinson’s disease medication. After an episode of agitation and rapid breathing was not reviewed by ward doctors, he suffered a respiratory arrest on 19 August 2013, was found to have had a heart attack, developed bronchopneumonia and died on 27 August 2013. The concerns identified included inconsistent administration of Parkinson’s medication, limited availability of doctors for non-emergency weekend reviews, and an unexplained hospital pharmacy dispensing error.

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 administer PD medication in accordance with patients’ usual regimens
Wider context from the report
“(1) I heard evidence that the administration of PD medication in hospital routinely does not follow patients’ usual regimens and that this, in itself, could cause physiological stress and contribute to early death. It was not possible conclude that, on the balance of probabilities, this was the case in Mr Brookes death but it was clear that this was a continuing risk, which could result in future deaths. ”
Source location
Peter John BROOKES · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Disseminate reminders about timely Parkinson’s medication through the Quality and Safety newsletter, linked resources, video, and the Clinical Practice Facilitators forum.

Verbatim wording from the response
“The Trust recognises the importance of ensuring medications, particularly those relating to PD and other time sensitive medication are taken in accordance with the patient’s usual medication schedule. A key approach to this in the Trust’s specialist PD area is through promoting and encouraging self medication where appropriate.”

Source location
2014-0205-Response-by-University-College-London-Hospitals-NHS-Foundation-Trust
Page 2 · response
Published 7 May 2014
Open published response
8 Apr2014
Plymouth, Torbay and South Devon
Concerns raised1
1. Failure to address suspected non-compliance with lifelong anticoagulation
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review advice given when patients begin anticoagulation.
  Stated by Oakside SurgeryStated completed
2. Action
  Compose a letter informing patients of the risks of non-concordance with medication.
  Stated by Oakside SurgeryStated in progress
AI-generated summary

Leslie Edmund Harding (Lez) · 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

Leslie Edmund Harding had a history of multiple sclerosis and recurrent pulmonary emboli, and died after collapsing on 28 September 2013. The report raised concerns about the lack of action after he was assessed with chest pain and suspected pulmonary embolus, gaps in anticoagulation prescribing and follow-up, insufficient efforts to address alleged non-compliance, and the absence of a prompt significant events review.

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 address suspected non-compliance with lifelong anticoagulation
Wider context from the report
“3. At Inquest, I gained the impression that Lez was felt to be non-compliant with his anti-coagulation regime. It was plain from the prescription history that there were repeated gaps in the provision of medication that Lez required. There seemed, however, in my view, to have been little effort given to addressing the reasons why, or indeed if, Lez actually was non-compliant with his medication. By way of illustration, I was not shown a letter from the Surgery to Lez bringing to his attention that he had failed to collect his monthly supply of Clexane and warning him of the risks of failing to maintain the treatment regime. I heard evidence at Inquest that Lez could be an awkward patient. In my view, of itself, that is insufficient reason not to make every reasonable effort to ensure that a patient complies with an identified need for lifelong anti-coagulation. ”
Source location
Leslie Edmund Harding (Lez) · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review advice given when patients begin anticoagulation.

Verbatim wording from the response
“3) As a result of this situation, I have reviewed the advice given to people when they first begin anti-coagulation and as a practice we are in the process of composing a letter informing people of the risks of non-concordance with medication.”

Source location
2014-0169-Response-by-Oakside-Surgery
Page 2 · response
Published 8 April 2014
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Compose a letter informing patients of the risks of non-concordance with medication.

Verbatim wording from the response
“3) As a result of this situation, I have reviewed the advice given to people when they first begin anti-coagulation and as a practice we are in the process of composing a letter informing people of the risks of non-concordance with medication.”

Source location
2014-0169-Response-by-Oakside-Surgery
Page 2 · response
Published 8 April 2014
Open published response
19 Sep2013
Gloucestershire
Concerns raised1
1. Insufficient arrangements to support taking anti-convulsant medication
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Conduct internal medicines-management audits across all nine Trust communities to assess compliance with safety standards.
  Stated by The Camphill Village TrustStated completed
2. Action
  Implement a Trust-wide Medicines Policy governing the obtaining, recording, handling, storage, administration and disposal of medicines.
  Stated by The Camphill Village TrustStated completed
3. Action
  Carry out medicines-policy compliance checks at least every six months under the Operations Director’s direction.
  Stated by The Camphill Village TrustStated planned
1. Action
  Require documented medicine risk assessments, capacity assessments and support instructions, with six-monthly or trigger-based reviews.
  Stated by The Camphill Village TrustStated completed
2. Action
  Incorporate regular training on managing risks associated with medicines into the Trust staff training plan.
  Stated by The Camphill Village TrustStated completed
3. Action
  Audit risk-assessment, capacity-assessment and documented-medicine-support records at least every six months.
  Stated by The Camphill Village TrustStated planned
4. Action
  Share the Coroner’s concerns with operational managers to support open learning and required practice changes.
  Stated by The Camphill Village TrustStated planned
5. Action
  Implement common Trust-wide paperwork and work systems for identifying, assessing and managing medicine-related risks.
  Stated by The Camphill Village TrustStated planned
AI-generated summary

Daniel Onley · 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

Daniel Onley, a resident at Orchard House, was found face down in his bath on 22 June 2012 and was concluded to have died from sudden unexplained death in epilepsy. Concerns included insufficient support for taking anti-convulsant medication, inadequate management of medication-related risks, and insufficient evening supervision.

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
Insufficient arrangements to support taking anti-convulsant medication
Wider context from the report
“(1) That the arrangements in place to support Daniel to take his anti-convulsant medication were insufficient. ”
Source location
Daniel Onley · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct internal medicines-management audits across all nine Trust communities to assess compliance with safety standards.

Verbatim wording from the response
“Audit of existing arrangements”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 1 · response
Published 19 September 2013
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement a Trust-wide Medicines Policy governing the obtaining, recording, handling, storage, administration and disposal of medicines.

Verbatim wording from the response
“Policy revision”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 2 · response
Published 19 September 2013
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Carry out medicines-policy compliance checks at least every six months under the Operations Director’s direction.

Verbatim wording from the response
“Future audit of arrangements”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 2 · response
Published 19 September 2013
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Require documented medicine risk assessments, capacity assessments and support instructions, with six-monthly or trigger-based reviews.

Verbatim wording from the response
“Improvements to the management of risks associated with the administration of medicines in trust services”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 2 · response
Published 19 September 2013
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Incorporate regular training on managing risks associated with medicines into the Trust staff training plan.

Verbatim wording from the response
“Regular training on the management of risks has been incorporated into the Trust’s staff training plan.”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 3 · response
Published 19 September 2013
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Audit risk-assessment, capacity-assessment and documented-medicine-support records at least every six months.

Verbatim wording from the response
“Future audit of arrangements”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 3 · response
Published 19 September 2013
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Share the Coroner’s concerns with operational managers to support open learning and required practice changes.

Verbatim wording from the response
“6 Organisational Learning”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 4 · response
Published 19 September 2013
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement common Trust-wide paperwork and work systems for identifying, assessing and managing medicine-related risks.

Verbatim wording from the response
“The concerns expressed by the Coroner have been shared with operational managers in order to ensure lessons are learned openly and frankly and any required changes to practice are made. For example, as a result of organisational learning, common paperwork has been implemented across the Trust regarding the identification; assessment and management of risks related to handing medicines. The introduction of such a common paperwork and systems of work will greatly assist risk mitigation, improve consistency in operational practice and also provides an essential benchmark for quality auditing purposes.”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 4 · response
Published 19 September 2013
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Inadequate support for medication management

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Withdrawal of medication administration support despite known lack of insight and need for medication compliance

Concerns raised1

Failure to supervise medication taking as specifically instructed

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Inconsistent checks that detainees swallow issued medication

Concerns raised1

Lack of a policy for supervising all prescribed medication when medication access is identified as a patient risk

Concerns raised1

Unavailability of medication-taking advice when the prescribing doctor is absent

Concerns raised1

Failure to administer PD medication in accordance with patients’ usual regimens

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to address suspected non-compliance with lifelong anticoagulation

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Insufficient arrangements to support taking anti-convulsant medication

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8

Actions described in response 3

Actions described in response 3

Actions described in response 1

Actions described in response 2

Actions described in response 8