Epilepsy, 19 Sep 2013 – 19 Jun 2026
Epilepsy-related Prevention of Future Deaths reports
All dates19 Sep 2013 – 7 Sep 2026
Select SUDEP or Non-SUDEP to filter concerns and reports. 3 reports could not be assigned and remain in All only. Counts are PFD reports, not deaths.
About this dataset
We searched all 6,433 reports in the published corpus using a fixed text-search method, then assessed 317 candidates against source-based inclusion criteria. Ninety reports were included. Epilepsy had to be materially relevant to the death or a substantive coroner’s concern; incidental mentions were excluded.
Eligibility and SUDEP assignment were assessed with GPT-5.6 Sol and checked for valid source quotations. Assignment uses a balance-of-probabilities threshold: SUDEP or non-SUDEP must be more likely than not on the report’s evidence. The exact term SUDEP need not appear. Genuinely unclear eligible reports remain in All only. These are model-assisted documentary assessments, not independently validated clinical diagnoses.
The search can miss reports with sparse terminology or incomplete source text. This dataset does not represent all epilepsy deaths. Recurring concerns and responses are taken from the existing published evidence. Published corpus snapshot: 7 September 2026. Cohort selection updated 5 November 2026. The title shows the first and last included reports’ publication dates.
Reports over time
Matching reports published each year within the selected date range.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Matching reports sent to each recipient.
Most commonly raised concerns
All classifications 90 reports 19 Sep 2013 – 7 Sep 2026
- Unreliable seizure care and managementControls dedicated to recognising, assessing, monitoring, responding to and managing seizures are not reliably provided.9 reportsSelected
- Incomplete, inaccurate or unavailable clinical and care recordsClinical and care records are incomplete, inaccurate, inconsistent, unavailable or otherwise unreliable for safe care.7 reportsSelected
- Unsafe medication administrationA recurring failure of the medication-administration system to ensure that medicines are administered safely, accurately, promptly and as prescribed.6 reportsSelected
- Failure to ensure clinical investigation results are reliably available, interpreted and acted uponRecurring deficiency in the end-to-end management of clinical investigation results, including their availability, transmission, checking, review, interpretation, follow-up and escalation when needed.4 reportsSelected
- Inadequate driver licensing controls for road safetyDriver licensing systems do not reliably identify, record, review or restrict drivers whose inexperience, health or vehicle-related risk requires additional safeguards.4 reportsSelected
- Inadequate staff competence to provide first aidReports identify an unsafe first-aid capability condition across healthcare, care, custody and other staff. The recurring concern is the unreliability of staff competence to recognise emergencies and provide appropriate first aid, rather than any single training, refresher, assessment or practical-performance failure.4 reportsSelected
- Unreliable hospital discharge processesHospital discharge does not reliably bring together planning, clinical readiness, relevant organisations, safe execution and required follow-up.4 reportsSelected
- Failure to communicate clinically important information reliably between care servicesRecurring concern that clinically important guidance, decisions and patient information are not kept accurate, current and available to the clinicians and emergency services who need them.3 reportsSelected
- Failure to provide required medication promptly when clinically neededThe anchor identifies delayed prescribing of a patient's usual medication after an unexpected admission, while another report identifies delayed prescribing and non-provision of urgent therapeutic medication. These support a recurring concern about timely provision of clinically required medication rather than only the anchor's admission or prescribing-step failure.3 reportsSelected
- Failure to provide timely clinical follow-up after medication prescribingPrescribed medication is not reliably followed up for effectiveness, safety, collection, adherence and patient response.3 reportsSelected
- Failure to seek medical attention when a person's condition warrants itReports identify an unreliable escalation control in which care staff or other responders do not promptly seek medical or paramedic assistance when a person's injury, pain, fall or deterioration warrants clinical attention.3 reportsSelected
- Insufficient police training for safe recognition and response to mental-health and behaviour-related medical crisesReports identify insufficient police training to recognise and respond safely to mental-health crises and behaviour-related medical emergencies.3 reportsSelected
- Insufficient qualified healthcare staffing capacityHealthcare services lack enough appropriately qualified staff to provide the required clinical coverage and patient care safely for the workload, acuity and specialist needs.3 reportsSelected
- Unreliable DVLA medical fitness notification arrangementsThe anchor identifies limited professional awareness and uncertain effectiveness of guidance for notifying the DVLA about medically relevant driving risks. A different report identifies clinicians failing to advise patients with cough syncope to stop driving and notify the DVLA, while another identifies failure to notify the DVLA of relevant medical conditions. These support the named DVLA medical-fitness notification process rather than guidance awareness alone.3 reportsSelected
- Unreliable communication of patient-care information between clinical staffClinical staff responsible for the same patient's care do not reliably exchange relevant information about care, treatment and risk.3 reportsSelected
- Unreliable healthcare patient transfer processesHealthcare transfers do not reliably provide the procedures, responsibility, documentation and clinical information needed for safe movement and continuity of care.3 reportsSelected
- Unreliable mental health referral pathwaysReports identify different failures within the mental health referral process, including referrals not being made when indicated, received referrals not being actioned, and frontline practitioners lacking clarity about when and where to refer. These support a recurring concern with the reliability of mental health referral pathways rather than any single referral or awareness failure.3 reportsSelected
- Unreliable patient observation arrangementsPatient observation systems do not reliably set, support and deliver the observation level required by assessed safety risk.3 reportsSelected
- Unsafe interoperability between prison custody and healthcare proceduresReports identify failures in the bounded interface between prison custody, contracted custody providers and healthcare services, where procedures, responsibilities and safety-relevant information do not operate together reliably.3 reportsSelected
- Electronic patient records failing to make relevant clinical information available and actionableRecurring concern that electronic patient-record systems do not reliably present, preserve, share or prompt action on clinically relevant information across the patient’s care.2 reportsSelected
- Failure to communicate safety-critical care information effectively between care providers and familiesReports identify unsafe communication between care providers and families, including failures to convey risks, care instructions, concerns or other information needed to support safe care and decision-making.2 reportsSelected
- Failure to conduct required welfare checks on people in distressThe anchor identifies a risk that care home staff will not check a resident in distress, while a different canonical report identifies failure to conduct a later welfare check on a person left in potential medical distress. Together these support a recurring concern about welfare checks not being completed when a person may require assistance.2 reportsSelected
- Failure to ensure safe prisoner transfersRecurring concern that the end-to-end prisoner transfer process is unreliable, leaving transferred prisoners exposed to unmanaged risks or interruptions in essential support.2 reportsSelected
- Failure to identify and address recurring safety issues through organisational learningDifferent reports identify failures of reporting, review and learning arrangements to retain, recognise and address substantive or recurring patient-safety issues, rather than merely failures to complete one specific corrective action.2 reportsSelected
- Failure to reliably document the rationale for consequential decisionsDifferent reports identify missing or inadequate records explaining the rationale and evidential basis for consequential decisions, including the anchor’s crucial decisions and comparable mental-capacity, NRPF and transfer decisions. The shared concern is unreliable rationale documentation for decisions that affect safety, accountability and continuity of care, rather than any one decision type or record system.2 reportsSelected
- Failure to reliably learn from medication incidents and implement safeguardsThe medication incident learning process is unreliable: incidents are not consistently followed up or reviewed to identify, communicate and implement safeguards that protect patients from recurrence.2 reportsSelected
- Failure to reliably recognise and respond to acute clinical deteriorationClinical deterioration is not reliably recognised, monitored, escalated and acted upon with the urgency it requires.2 reportsSelected
- Failure to reliably refer patients to required specialist servicesThe anchor identifies a required physiotherapy referral that was not completed. A different report identifies delayed referrals to physiotherapy, occupational therapy, dietetics and Parkinson’s specialist services. Together these support an end-to-end concern with required specialist referrals not being made promptly and reliably, rather than a concern limited to one physiotherapy referral.2 reportsSelected
- Failure to secure and control medicationReports identify medication as remaining accessible, unsecured or inadequately controlled, creating risks of misuse, overdose, theft or access by people other than the intended patient.2 reportsSelected
- Inadequate control of illicit substance use and supply in secure institutionsThe anchor identifies an ongoing failure to mitigate illicit substance entry, distribution and use in a secure hospital, while assertions from different reports identify continuing illicit-drug influx, widespread access and weak supply-reduction controls in prisons. These distinct manifestations support a bounded concern about controlling illicit substances in secure institutional settings, rather than only room searches, drug testing or a prison-specific strategy.2 reportsSelected
- Inadequate controls on contraband mobile phones in prisonsDifferent reports identify failures in the prison control system for preventing and mitigating access to contraband mobile phones, including their easy availability to prisoners and their use to facilitate drug dealing and other prison-security risks.2 reportsSelected
- Inadequate recording of medication prescribing decisionsReports identify unreliable medication prescribing records that can obscure prescribing status, rationale, changes or safety-critical decisions and thereby allow unsafe medication to be prescribed or administered.2 reportsSelected
- Incomplete clinical history-takingReports identify an unsafe clinical assessment condition in which relevant patient history is not obtained sufficiently to support recognition of symptoms, risks and appropriate care.2 reportsSelected
- Unreliable Care Programme Approach care coordinationReports identify different failures within the named Care Programme Approach, including the absence of a structured medication review and failures to allocate coordinators, complete required reviews, maintain care plans and follow up patients. Together these support a recurring concern with the reliable operation of CPA care coordination rather than medication review alone.2 reportsSelected
- Unreliable RIO clinical-record functionsThe anchor identifies an unclear timeliness standard for RIO entries, while different reports identify failures of RIO to support complete information capture, cross-team access and usable observation records. Together these support a recurring concern with the reliability of the named RIO clinical-record system rather than only one entry-timing or documentation manifestation.2 reportsSelected
- Unreliable access to emergency communicationReports identify failures in dedicated emergency communication arrangements that can delay summoning or contacting emergency help.2 reportsSelected
- Unreliable communication of critical medication information to GPsRecurring deficiency in the medication-information exchange process between services and GPs, including information needed to maintain supplies, assess prescribing safety and support continuity of treatment.2 reportsSelected
- Unreliable escalation by care staff for required medical attentionCare staff do not reliably recognise and escalate deterioration, pain or other safety concerns to obtain timely medical assessment or advice.2 reportsSelected
- Unreliable implementation of medication changesReports identify different failures in the medication-change process, including failure to act on a prescribed reduction, failure to ensure carers acknowledge changes, and difficulty implementing specialist-directed changes accurately. Together these support the wider unsafe condition that medication changes are not reliably implemented across prescribing, communication and follow-up controls.2 reportsSelected
- Unreliable inter-agency information sharing for coordinated careThe anchor identifies absent agreed communication means and inaccessible shared patient information between mental health agencies. Other canonical reports identify relevant risk information not being shared between agencies and poor inter-agency information sharing preventing coordinated care, supporting a recurring concern with the reliability of inter-agency care information sharing rather than only the anchor's repository or communication-channel failure.2 reportsSelected
- Unreliable management of medication doses not takenThe anchor identifies missing guidance for monitoring prescribed medication that self-administering patients do not take when dispensed. A different report identifies inconsistent procedures for responding when service users refuse or do not take medication. Together these support a recurring concern with the reliability of detecting, monitoring and escalating omitted or refused medication doses, rather than a concern limited to one guidance document or one home's procedure.2 reportsSelected
- Unreliable medication dosage verification and communicationReports identify unsafe failures to ensure that medication dosages are accurately verified, clarified and communicated across prescribing, dispensing and administration activities.2 reportsSelected
- Unreliable observation of people in custodyThe anchor report identifies failure to transfer and replicate medically required observation levels when a detained person moves into GEO AMEY custody, while a different report identifies uncertainty about whether the correct observation level, including constant watch, was provided to a person in prison custody. Together these support a recurring concern about the reliability of the custody observation process rather than only one handover or level-setting failure.2 reportsSelected
- Unreliable recording of required observations in care and custodyDifferent reports identify inaccurate, delayed, anticipatory or falsified records of required observations, including 15-minute observations in prison custody and patient-care settings. The shared unsafe condition is that observation records do not reliably reflect when and how observations were actually conducted, rather than any one observation frequency, recording location or electronic system.2 reportsSelected
- Unreliable review and action on clinically significant incoming correspondenceReports identify failures across the incoming clinical-correspondence process, including failure to identify GP medication-review requests, failure to bring action-requiring correspondence to medical staff, and correspondence being filed without GP review or action. The shared unsafe condition is that clinically significant correspondence may not reliably reach the responsible clinician or trigger the required clinical response.2 reportsSelected
- Unreliable safety CCTV monitoring systemsDifferent reports identify failures in the operation of CCTV used as a safety control, including absent staff access arrangements, inadequate coverage, non-working cameras, insufficient monitoring and unclear staff instructions. Together these support the reliability of safety CCTV monitoring as the parent concern rather than any single access, coverage, equipment or training failure.2 reportsSelected
- Unreliable urgent mental health referral and assessment pathwaysUrgent mental-health referral pathways do not reliably secure timely access, coordination and specialist assessment.2 reportsSelected
- Unreliable welfare-check processes for people whose health is of concernThe anchor identifies unclear purpose and use of the welfare sheet for monitoring prisoners whose health is of concern. A separate report identifies inconsistent criteria for what constitutes a welfare check and when it is recorded. Together these support a recurring concern with the reliability of the bounded welfare-check process, rather than only the sheet or recording component.2 reportsSelected
- Unsafe cell-sharing decisions for prisonersRecurring deficiencies in the prison cell-sharing risk system can leave prisoners exposed to unsafe pairings or prevent them from understanding changes affecting their cell-sharing status.2 reportsSelected
- Unsafe medication prescribingReports identify unsafe prescribing decisions in which the medication, indication, dose or relevant clinical circumstances are not adequately evaluated before prescribing.2 reportsSelected
All reports in this date range
19 Sep 2013 – 7 Sep 2026 · 90 reports
Showing all concerns and their linked actions and positions from reports in this date range. Select a recurring concern above to narrow the evidence.
Actions and positions describe what recipients stated in published responses. Select a statement to read its source wording.
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Concerns raised6
Failure to fully investigate prisoners’ reported episodes of loss of consciousness
Failure to conduct NICE-compliant investigations of loss of consciousness
Failure to make accurate and evidentially grounded entries in prisoners’ medical notes
Failure to conduct clinical investigations of prisoners experiencing loss of consciousness
Failure to take full account of family history when clinically investigating prisoners with possible high cholesterol
Lack of doctors’ awareness of NICE guidelines for transient loss of consciousness
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised4
Failure of emergency-response policy to require requesting duty doctor attendance
Failure of nursing staff to respond to collapses in a calm coordinated manner
Failure of nursing staff to apply basic life-support training
Lack of clear staff-response guidance for collapses
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.6
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Action
Review the Trust resuscitation policy to address emergency response guidance.
Stated by North London NHS Foundation Trust -
Action
Update the resuscitation policy with deteriorating-patient actions, an expanded NEWS Score, and a requirement to contact the duty doctor during medical emergencies.
Stated by North London NHS Foundation Trust -
Action
Revise and regularly run lifelike-manikin resuscitation assessments and practical sessions across Forensic Service and Trust wards.
Stated by North London NHS Foundation Trust
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Action
Display step-by-step breathing-assessment and emergency-response guidance across all Forensic Service ward areas.
Stated by North London NHS Foundation Trust -
Action
Introduce the step-by-step emergency-response guide in all other inpatient areas.
Stated by North London NHS Foundation Trust -
Action
Conduct unannounced resuscitation scenarios across Forensic wards to strengthen emergency response.
Stated by North London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The resuscitation policy already listed actions for determining whether a collapsed patient was breathing and responding to such events.
Stated by North London NHS Foundation Trust
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Concerns raised9
Delays in medical treatment following pneumothorax
Failure to recognise pneumothorax on X-rays
Inadequate recording of nasogastric tube placement
Feeding via nasogastric tube before completion of full checks
Failure to record nasogastric tube feeding authorisation
Inappropriate use of nasogastric tubes for patients with advanced dementia and seizures
Unexplained gaps in clinical notes
Delays in forwarding and receiving X-ray reports from radiology
Breakdown in communication between junior doctors and consultants
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to access and read all relevant information across nursing and clinical records
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised13
Failure to complete MEDACS assessment forms and care plans accurately
Failure to document non-assessment and avoid misleading medical records
Failure to obtain and review detained persons’ relevant medical information
Lack of understanding of required custody observation levels and rationale
Failure to accurately document custody cell checks
Failure to complete prisoner transfer documentation accurately
Failure to staff the Prisoner Processing Unit overnight
Lack of staff knowledge of MEDACS policies and protocols
Failure to transfer and replicate medical observation information during GEO AMEY custody
Lack of specific instructions and effective positioning for CCTV cell monitoring
Ineffective or absent handovers between custody staff
Failure to accurately record custody visits and checks
Failure to record custody risk assessments and rationale for unchanged assessments
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.17
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Action
Print clinicians’ electronic care plans for custody sergeants to reduce discrepancies between clinical and police records.
Stated by Medacs Healthcare Plc -
Action
Review the electronic medical-record system to determine whether screening tools and mandatory completion controls should be added.
Stated by Medacs Healthcare Plc -
Action
Conduct annual audits of clinicians’ medical-note quality, address concerns individually and complete the scheduled re-audit.
Stated by Medacs Healthcare Plc
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Action
Train and audit clinicians on completing the electronic medical record, including care plans and significant negative answers.
Stated by Medacs Healthcare Plc -
Action
Conduct weekly electronic-record-use audits and address issues identified with clinicians.
Stated by Medacs Healthcare Plc -
Action
Operate a computerised MEDACS clinical-record system requiring typed 708e forms and direct transcription into the ICIS custody system.
Stated by Greater Manchester Police -
Action
Enable MEDACS clinicians to enter care plans directly into the custody system.
Stated by Greater Manchester Police -
Action
Use electronic records instead of handwritten forms, removing the requirement to label examinations as completed or refused.
Stated by Medacs Healthcare Plc -
Action
Require clinicians to obtain custody-sergeant handovers and follow pre- and post-assessment guidance to review relevant medical history, medication and previous entries.
Stated by Medacs Healthcare Plc -
Action
Amend MEDACS observation-level dropdown menus to improve clarity.
Stated by Greater Manchester Police -
Action
Provide staff inputs using case studies to reinforce recording risk-assessment rationales and custody actions accurately.
Stated by Greater Manchester Police -
Action
Issue and check improved guidance for sergeants on completing, timing and signing off Prisoner Escort forms.
Stated by Greater Manchester Police -
Action
Maintain hard-copy and electronic policy access in every custody suite and disseminate revised policies through lead clinicians.
Stated by Medacs Healthcare Plc -
Action
Require new healthcare staff to complete three-day clinical shadowing and sign that they received guidance on locating and using policies.
Stated by Medacs Healthcare Plc -
Action
Develop a custody-office work system that improves CCTV monitoring coverage and accountability.
Stated by Greater Manchester Police -
Action
Standardise sergeant handovers around accurate Custody Summary Screens and communication of key detainee risk information.
Stated by Greater Manchester Police -
Action
Require recording of unchanged risk assessments and monitor compliance through Custody Inspector dip sampling.
Stated by Greater Manchester Police
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Staff cannot record every question, answer or refusal, but must record significant information.
Stated by Medacs Healthcare Plc
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Position
Assessments cannot always be completed because detainees may refuse to cooperate or answer health questions.
Stated by Medacs Healthcare Plc -
Position
Existing CCTV arrangements are considered sufficient; staff will not be specifically instructed to observe the screen for Level 2 observations.
Stated by Greater Manchester Police
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Concerns raised5
Hand sanitiser gel stored within possible patient reach in A&E
Failure to keep A&E nursing notes complete and up to date
Failure to record nursing-observation frequency on the A&E whiteboard
Uncertainty over assessment on arrival at A&E
Failure to take hourly nursing observations in A&E
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.4
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Action
Check hand-gel dispensers regularly, keep them correctly located and maintained, and replenish them when required.
Stated by South Tees Hospitals NHS Foundation Trust -
Action
Make staff aware of the importance of keeping the area clean and tidy and reporting environmental problems immediately.
Stated by South Tees Hospitals NHS Foundation Trust -
Action
Return hand-gel dispensers to their correct locations throughout the department.
Stated by South Tees Hospitals NHS Foundation Trust
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Action
Remind nursing staff to complete and accurately record patient observations.
Stated by South Tees Hospitals NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The department’s layout and distributed hand-gel dispensers meant staff did not have a significant distance to travel between cubicles.
Stated by South Tees Hospitals NHS Foundation Trust
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Position
The Trust found no evidence that Mr Collins could access hand gel at the nurses’ station or that this contributed to his death.
Stated by South Tees Hospitals NHS Foundation Trust -
Position
Trust policy considered the Early Warning Score insufficient to require medical review, so observation levels and frequency were managed under existing arrangements.
Stated by South Tees Hospitals NHS Foundation Trust
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Concerns raised3
Failure to correctly diagnose patients' conditions
Failure to provide truthful information about seeking clinical second opinions
Continued practice by a GP whose fitness to practice is in doubt
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
The five-year statutory rule and unsuccessful exceptional-circumstances test prevented further investigation of the historical events and audit.
Stated by General Medical Council
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Position
Responsible Officer oversight, complaint reporting and periodic revalidation were considered sufficient to address concerns about current fitness to practise.
Stated by General Medical Council
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Concerns raised3
Risk of unnecessary death or injury to residents treated without appropriate assessment of unconsciousness
Failure to provide early medical attention for gradual onset stroke
Failure to seek medical opinion for prolonged unconsciousness
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.6
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Action
Provide all staff with first-aid and life-support training focused on the immediate care of unconscious residents.
Stated by Springbank Care Home Limited -
Action
Assess nurses’ competency in recognising consciousness levels, providing and documenting life support, conducting neurological observations, and following relevant guidance.
Stated by Springbank Care Home Limited -
Action
Instruct staff to summon emergency services promptly for unconscious residents, follow valid DNNAR instructions, and use a protocol available to all staff.
Stated by Springbank Care Home Limited
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Action
Inform nurse agencies and provide their head offices with the unconscious-person management protocol.
Stated by Springbank Care Home Limited -
Action
Provide the unconscious-person management protocol to occasional staff through agency induction materials.
Stated by Springbank Care Home Limited -
Action
Update residents’ risk assessments and care plans with specific information about causes of unconsciousness, including detailed epilepsy seizure types and recovery periods.
Stated by Springbank Care Home Limited
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Concerns raised3
Failure to notify Social Services of discharge contrary to their recommendations
Lack of clarity in communicating post-discharge supervision expectations to informal carers
Failure to maintain complete and accurate records of discharge decisions and timing
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised3
Insufficient supervision to safeguard safety and wellbeing
Failure to manage risks associated with medication management
Insufficient arrangements to support taking anti-convulsant medication
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.11
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Action
Review service staffing adequacy periodically through performance and contract monitoring.
Stated by The Camphill Village Trust -
Action
Establish General Manager and Care and Support Manager posts and appoint additional competent support staff at the Grange.
Stated by The Camphill Village Trust -
Action
Remind managers to provide supervision at all times commensurate with each person’s assessed needs.
Stated by The Camphill Village Trust
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Action
Share the Coroner’s concerns with operational managers to support open learning and required practice changes.
Stated by The Camphill Village Trust -
Action
Implement a Trust-wide Medicines Policy governing the obtaining, recording, handling, storage, administration and disposal of medicines.
Stated by The Camphill Village Trust -
Action
Incorporate regular training on managing risks associated with medicines into the Trust staff training plan.
Stated by The Camphill Village Trust -
Action
Audit risk-assessment, capacity-assessment and documented-medicine-support records at least every six months.
Stated by The Camphill Village Trust -
Action
Conduct internal medicines-management audits across all nine Trust communities to assess compliance with safety standards.
Stated by The Camphill Village Trust -
Action
Implement common Trust-wide paperwork and work systems for identifying, assessing and managing medicine-related risks.
Stated by The Camphill Village Trust -
Action
Require documented medicine risk assessments, capacity assessments and support instructions, with six-monthly or trigger-based reviews.
Stated by The Camphill Village Trust -
Action
Carry out medicines-policy compliance checks at least every six months under the Operations Director’s direction.
Stated by The Camphill Village Trust
