19 Oct 2017 Ronald Maurice Brewer · Prevention of Future Deaths report Gloucestershire
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Concerns raised 1
Deficiencies in the administration of medications View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Barchester Healthcare Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Barchester Healthcare Limited
Appoint a palliative-care Deputy Manager to support end-of-life training and practice, supervise implementation, and develop local palliative-care team involvement.
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Barchester Healthcare Limited
Provide further staff training on medicine management and record keeping.
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Barchester Healthcare Limited
Deliver three months of training covering end-of-life planning, anticipatory care, communication, medication decision-making, and medication management.
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Barchester Healthcare Limited
Revisit end-of-life and medication policies with staff and reinforce multidisciplinary working.
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Barchester Healthcare Limited
Update end-of-life and medication policies with guidance on individualised dosing decisions for prescribed dosage ranges, including analgesia and controlled medicines.
View source
Barchester Healthcare Limited
Use the Zomorph recording error as a learning point in staff supervision, training, and assessment.
View source
Barchester Healthcare Limited
Update central medicine-management and end-of-life policies to reflect good practice.
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AI-generated summary
Ronald Maurice Brewer · 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
Ronald Maurice Brewer was an 87-year-old man with significant medical conditions who was admitted to hospital, discharged to a care home for end-of-life care, and died shortly after receiving prescribed palliative and anticipatory medication. The substantive concern related to the administration, documentation, and dispensing of palliative medications.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Deficiencies in the administration of medications
Wider context from the report “1. The administration of medications , including in particular the documentation of and dispensation of palliative medications.
” Source location Ronald Maurice Brewer · Prevention of Future Deaths report
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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 Appoint a palliative-care Deputy Manager to support end-of-life training and practice, supervise implementation, and develop local palliative-care team involvement.
Verbatim wording from the response “a. A Deputy Manager has been appointed at Badgeworth Court with a background in palliative care and she has been given the responsibility to support training and practice in end of life care in the home. Also to continue” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
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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 Provide further staff training on medicine management and record keeping.
Verbatim wording from the response “b. The staff at Badgeworth Court have undertaken an assessment of their competencies and practices in relation to management of medicines and they have attended further training on this topic and in relation to record keeping.” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver three months of training covering end-of-life planning, anticipatory care, communication, medication decision-making, and medication management.
Verbatim wording from the response “d. The General Manager at Badgeworth has arranged for ongoing training over the next 3 months, the training is to cover;” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
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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 Revisit end-of-life and medication policies with staff and reinforce multidisciplinary working.
Verbatim wording from the response “e. The end of life and management of medication policies have been re-visited with staff and we have reiterated the importance of multi-professional working in end of life care.” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update end-of-life and medication policies with guidance on individualised dosing decisions for prescribed dosage ranges, including analgesia and controlled medicines.
Verbatim wording from the response “g. In our review it was noted that during Mr Brewer’s end of life care, a decision was made to administer Midazolam at a dose at the highest end of the prescribed dose range. Our finding was that the decision was appropriate and was made by an experienced nurse having considering the individual factors specific to Mr Brewer including his height, weight and level of agitation. Nevertheless, it was identified that more could be done to support” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the Zomorph recording error as a learning point in staff supervision, training, and assessment.
Verbatim wording from the response “i. Whilst investigating the drug administration notes and checking remaining stocks of Zomorph it was noted that a recording error had taken place during the first administration of the drug at Badgeworth Court. The dose had been recorded on the hospital MAR chart instead of the newly created home MAR chart. The error created two distinct risks;” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
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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 Update central medicine-management and end-of-life policies to reflect good practice.
Verbatim wording from the response “j. Policies and procedures have been updated centrally to reflect good practice in medicine management and End of life care.” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The highest-end prescribed Midazolam dose was considered appropriate, based on the resident’s individual factors and agitation.
Verbatim wording from the response “g. In our review it was noted that during Mr Brewer’s end of life care, a decision was made to administer Midazolam at a dose at the highest end of the prescribed dose range. Our finding was that the decision was appropriate and was made by an experienced nurse having considering the individual factors specific to Mr Brewer including his height, weight and level of agitation. Nevertheless, it was identified that more could be done to support” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
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5 Oct 2017 Jennifer Ann Midgley · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 2
Failure of the drug administration chart to distinguish oral and intravenous paracetamol administration View source Lack of patient-weight reference for intravenous paracetamol administration View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Jennifer Ann Midgley · 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
Jennifer Ann Midgley had chronic obstructive pulmonary disease, malnutrition, non-alcoholic fatty liver disease and cirrhosis. After fracturing her left femur and undergoing surgery, she received intravenous paracetamol that was not adjusted for her weight, and this was described as contributing to organ failure and her death. The concerns included unclear drug administration charting distinguishing oral from intravenous paracetamol and the lack of a recorded patient weight for intravenous dosing.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the drug administration chart to distinguish oral and intravenous paracetamol administration
Wider context from the report “(1) I was informed that the drug administration chart does not clearly distinguish between the administration of oral and intravenous paracetamol , nor does it have any reference to a patient's weight in respect of intravenous administration.
” Source location Jennifer Ann Midgley · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of patient-weight reference for intravenous paracetamol administration
Wider context from the report “(1) I was informed that the drug administration chart does not clearly distinguish between the administration of oral and intravenous paracetamol, nor does it have any reference to a patient's weight in respect of intravenous administration .
” Source location Jennifer Ann Midgley · Prevention of Future Deaths report
Open source report
Concerns raised 2
Lack of clarity in recording whether Alteplase was followed by an infusion View source Poor recording of medication delivery View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Captain James Michael Bedford · 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
Captain James Michael Bedford, a senior long-haul airline pilot, developed a left-leg deep vein thrombosis and later collapsed after a flight from China. He suffered a pulmonary embolus and cerebral events, followed by an acute cerebral haemorrhage after treatment with heparin, and died on 30 June 2015. Concerns included differing hospital practices regarding lower-leg scanning for DVT and whether a full-leg scan at his first attendance might have provided an opportunity for treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clarity in recording whether Alteplase was followed by an infusion
Wider context from the report “5. There was no criticism of the use of 50mg Alteplase but there was a lack of clarity as to whether this was followed by an infusion . A further expert witness (a haematologist) criticised the subsequent use of unfractionated Heparin and a test of Heparin level seems to have taken a long time from sampling to delivery to the laboratory and later result. The evidence was strongly suggestive of over-anticoagulation by Heparin.
” Source location Captain James Michael Bedford · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Poor recording of medication delivery
Wider context from the report “6. A number of issues were raised as to note-keeping or clarity of note-keeping, most particularly as regards delivery of medications .
” Source location Captain James Michael Bedford · Prevention of Future Deaths report
Open source report
12 Oct 2016 Rohid SHERGILL · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Failure of clinicians visiting sick children at home to perform or confirm pH testing before medication administration View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Rohid SHERGILL · 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
Rohid Shergill, who had Duchenne’s muscular dystrophy and was fed through a nasogastric tube, died on 14 March 2016 after the tube was inserted into his lung and was used for feeding and medication. The principal concerns included inadequate checking of the tube position, uncertainty about parental understanding of pH testing, insufficient information-sharing between trusts, unclear care coordination, and possible contamination from repeated syringe use.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of clinicians visiting sick children at home to perform or confirm pH testing before medication administration
Wider context from the report “4. Training to physiotherapy teams regarding the importance of pH testing (or at least confirming this has been done) before administration of medication. This should be considered for other disciplines who routinely visit sick children at home and prescribe medication – such as occupational therapists / speech and language therapists.
” Source location Rohid SHERGILL · Prevention of Future Deaths report
Open source report
Concerns raised 1
Delays in administering antibiotics after knee aspiration View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Pamela June Conway · 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
Pamela June Conway developed an infected knee and experienced cumulative delays, including around 21 hours before receiving antibiotics, during which she went into irrevocable septic shock. The concerns included the absence of a finalised care pathway for patients with an infected prosthesis and an almost two-hour delay between knee aspiration and antibiotic administration. The inquest recorded that her death was due to natural causes exacerbated by delayed medical treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in administering antibiotics after knee aspiration
Wider context from the report “2. Furthermore evidence indicated that although it was always intended that antibiotics would be administered once the patient's knee had been aspirated, there was a delay of almost two hours between this procedure and the administration of antibiotics (a delay which was explained by being due to “normal hospital procedures” ).
” Source location Pamela June Conway · Prevention of Future Deaths report
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10 Aug 2016 Thomas George Jordan · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to discontinue prescribed medication when requested by hospital clinicians View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Thomas George Jordan · 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
Thomas George Jordan, a remand prisoner at Her Majesty’s Prison, Leeds, became unwell with cardiac symptoms and was admitted to hospital on 6 August 2015. His condition deteriorated, and he died following cardiac arrest at 1955 hours that day; the inquest recorded natural causes. The concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication when he was discharged from hospital, although the report stated there was no evidence that the drug error materially caused or contributed to his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to discontinue prescribed medication when requested by hospital clinicians
Wider context from the report “(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued .
(2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged.
(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them.
(4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death.
” Source location Thomas George Jordan · Prevention of Future Deaths report
Open source report
10 Aug 2016 Thomas George Jordan · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1
Failure to discontinue medication when directed by hospital clinicians View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Thomas George Jordan · 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
Thomas George Jordan, a remand prisoner at Her Majesty’s Prison, Leeds, became unwell with cardiac and other medical problems and died in hospital after suffering cardiac arrest on 6 August 2015. Concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication between the hospital and prison, although the report stated there was no evidence that the drug error materially caused or contributed to his death.
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× 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 discontinue medication when directed by hospital clinicians
Wider context from the report “(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued .
(2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged.
(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them.
(4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death.
(5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect.
(6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose.
” Source location Thomas George Jordan · Prevention of Future Deaths report
Open source report
Concerns raised 1
Lack of a mechanism ensuring essential medications are prescribed, dispensed and administered View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
David Aughton · 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
David Aughton sustained a severe traumatic brain injury in 1999 that led to epileptic seizures. During a hospital admission for a cystoscopy in December 2015, his anticonvulsant medication was not administered; he subsequently had a grand mal convulsion causing aspiration pneumonia and died on 25 January 2016. The principal concern was that there was no mechanism to ensure essential medications were prescribed, dispensed and administered.
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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 mechanism ensuring essential medications are prescribed, dispensed and administered
Wider context from the report “That despite the fact that his regular medications including lamotrigine and sodium valproate were recorded in his medical records, those medications had not been dispensed, leading to a grand mal convulsion it was apparent that there was no mechanism in place to ensure that essential medications were prescribed, dispensed and administered .
” Source location David Aughton · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to adjust paracetamol dosage for extremely low body weight View source
Linked response
the Rotherham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
the Rotherham NHS Foundation Trust
Review the Medicines Management Policy and develop local guidance, a standard operating procedure, or directive covering dose reduction for extremely low body weight.
View source
the Rotherham NHS Foundation Trust
Produce and disseminate pharmacy and junior-medical-staff information on reducing oral paracetamol doses for patients under 50 kilograms or with relevant risk conditions.
View source
the Rotherham NHS Foundation Trust
Develop prescription-chart stickers to raise awareness of oral and intravenous paracetamol dose-reduction guidance.
View source
the Rotherham NHS Foundation Trust
Develop information for nursing and medical staff on adjusting paracetamol dosage for adult patients with extremely low body weight.
View source
the Rotherham NHS Foundation Trust
Provide and record required staff training on paracetamol dose reduction, including training during induction.
View source
the Rotherham NHS Foundation Trust
Audit documentation of patient weights in clinical, nursing, and prescription records and present the results to the Patient Safety Group.
View source
the Rotherham NHS Foundation Trust
Deliver a learning event discussing the specific case as part of the September safety programme.
View source See 4 more actions
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Hayley Christine Clark · 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
Hayley Christine Clark, aged 36, was admitted to Rotherham General Hospital with electrolyte imbalance and received an unadjusted standard adult dose of paracetamol despite her extremely low body weight. Her condition deteriorated and she died on 24 May 2015; the inquest recorded severe multifactorial malnutrition among the causes of death. The substantive concern was that staff failed to recognise the need to reduce the paracetamol dosage for her low body weight.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to adjust paracetamol dosage for extremely low body weight
Wider context from the report “(1) There was a failure, on the part of the staff who prescribed and administered the Paracetamol to Ms Clark, to recognise the need to adjust the dosage (in evidence the required reduction was said to be 50%) to reflect Ms Clark’s extremely low body weight .
” Source location Hayley Christine Clark · Prevention of Future Deaths report
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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 Medicines Management Policy and develop local guidance, a standard operating procedure, or directive covering dose reduction for extremely low body weight.
Verbatim wording from the response “1. Ensure the Trust’s Medicines Management Policy includes the safe prescribing and administration of medication for patients with extremely low body weight.” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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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 Produce and disseminate pharmacy and junior-medical-staff information on reducing oral paracetamol doses for patients under 50 kilograms or with relevant risk conditions.
Verbatim wording from the response “1.2 A pharmacy medications information leaflet to be produced on reducing the dose of oral paracetamol for patients who weigh less than 50kgs and/or with medical conditions which may require consideration of dose reduction – malnutrition/anorexia or high alcohol consumption all of which are known indications for considering a dose reduction of oral paracetamol” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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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 prescription-chart stickers to raise awareness of oral and intravenous paracetamol dose-reduction guidance.
Verbatim wording from the response “1.3 Development of stickers to be used on the Trust’s prescription charts to raise awareness and compliance with the dose reduction guidance of oral (and IV) paracetamol” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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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 information for nursing and medical staff on adjusting paracetamol dosage for adult patients with extremely low body weight.
Verbatim wording from the response “2. Ensure all nursing and medical colleagues identify adult patients with extremely low body weight who may need adjustment in the dosage of oral paracetamol” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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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 Provide and record required staff training on paracetamol dose reduction, including training during induction.
Verbatim wording from the response “2.2 A record of all staff who require and have received appropriate training - on dosage reduction; will be collated to ensure all appropriate nursing and medical colleagues have received this in the required timescale” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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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 documentation of patient weights in clinical, nursing, and prescription records and present the results to the Patient Safety Group.
Verbatim wording from the response “2.3 Review of documentation to ensure accurate recording of patients weight in the clinical records, nursing records and prescription charts” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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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 Deliver a learning event discussing the specific case as part of the September safety programme.
Verbatim wording from the response “2.5 A learning event to be held to discuss the details of this specific case” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Body weight alone is not considered a marker of increased risk of oral paracetamol toxicity, although associated conditions may warrant dose reduction.
Verbatim wording from the response “What timescale has been set and agreed?
As the British National Formulary (BNF) does not currently provide dosage reduction recommendations the Trust’s Chief Pharmacist has sought advice from the Medicines and Healthcare products Regulatory Agency (MHRA) who have recently reviewed the publication of a paper from Birmingham Trust; whilst body weight alone is not considered a marker for an increased risk of oral paracetamol toxicity, an adult weighing less than 50kgs is more likely to have conditions that predispose them to liver damage from the paracetamol. A dose reduction to 2-3g total daily dose may be warranted. The MHRA are not currently recommending a change to the licences of oral paracetamol products, or a change to the packaging of the paracetamol products for the public to buy.” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
Open published response
25 Feb 2016 Betty Addison · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Insufficient control of medication administration at Alexandra Court Care Home View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Betty Addison · 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
Betty Addison fell while walking for a bus, sustained a fracture to her right femur, underwent surgery, and later died after collapsing at a care home on 2 December 2015. She was given five additional Dalteparin injections beyond those prescribed, raising concerns about the control and monitoring of medication administration at Alexandra Court Care Home, although the report states that the additional medication was not causative or contributory to her death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient control of medication administration at Alexandra Court Care Home
Wider context from the report “1. The administering of medications at Alexandra Court Care Home is not sufficiently controlled and other residents at the Home may be given medication other than in accordance with that prescribed, whether that is an excessive amount, or a reduced amount , as the 5 injections given to Mrs Addison must have come from somewhere and potentially another resident’s supply.
” Source location Betty Addison · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.