Recipient

Carewatch (Mid Bucks)

First report 13 Dec 2008•Latest report 13 Dec 2008

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Domiciliary care provider. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Carewatch (Mid Bucks) linked to the concerns in each report. Select any concern, action or position to view the source wording.

13 Dec2008
Buckinghamshire
Concerns raised6
1. Failure to record mobile-phone medication instructions and changes in patient records
2. Failure to ensure individual carers read and acknowledge patient medication changes
3. Failure to obtain individual carers’ signed acknowledgement of patient care plans
1. Lack of cross-checking to prevent carers repeating inherited medication errors
2. Failure to procure original patient records during investigations
3. Unavailability of electronic access to patients’ medication histories
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Heather Beatrice Planner · 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

Heather Beatrice Planner died at Wycombe Hospital on 1 April 2019 from a gastrointestinal bleed in the context of large bowel ischaemia. The report states that she had not received her prescribed apixaban anticoagulation at home for two days before admission, and identifies concerns about medication administration, communication and record-keeping processes for carers, as well as the subsequent investigation.

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. The report was sent to Carewatch (Mid Bucks); that does not assign responsibility.
PFD Monitor interpretation
Failure to record mobile-phone medication instructions and changes in patient records
Wider context from the report
“(4) There does not appear to be a system for recording on a patient’s records specific medication instructions or changes to medication which might have been given or taken by mobile phone. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Carewatch (Mid Bucks); that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure individual carers read and acknowledge patient medication changes
Wider context from the report
“(1) Changes to an individual patient’s medication are emailed to carers and a new prescription (MAR) chart is issued but there is no procedure in place to ensure that individual carers have read and specifically acknowledged any medication changes. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Carewatch (Mid Bucks); that does not assign responsibility.
PFD Monitor interpretation
Failure to obtain individual carers’ signed acknowledgement of patient care plans
Wider context from the report
“(3) There does not appear to be any process for individual carers to sign to acknowledge having read and implemented a patient’s care plan in the patient’s log book. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Carewatch (Mid Bucks); that does not assign responsibility.
PFD Monitor interpretation
Lack of cross-checking to prevent carers repeating inherited medication errors
Wider context from the report
“(2) It is unclear what additional measures or cross-checking have been introduced to prevent a subsequent carer, who is attending a patient, from inheriting a medication error from an earlier attendance and repeating that error. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Carewatch (Mid Bucks); that does not assign responsibility.
PFD Monitor interpretation
Failure to procure original patient records during investigations
Wider context from the report
“(6) There is a specific concern in Mrs Planner’s case about the robustness of the subsequent Carewatch investigation and any learning that would arise to prevent incidents in the future, since Carewatch had not procured the original paper patient records from Mrs Planner’s home address at any stage during their investigations or prior to the inquest hearing. This may have compromised the ability to assess the accuracy of records to which the individual carers had access, any impact that may have had upon the medication error, or any learning to arise in the context of record keeping and application of medication and care plan requirements by carers. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Carewatch (Mid Bucks); that does not assign responsibility.
PFD Monitor interpretation
Unavailability of electronic access to patients’ medication histories
Wider context from the report
“(5) There does not appear to be any electronic system or record to enable carers to access a patient’s medication history, the records at the patient’s home being only paper records. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised6

Failure to record mobile-phone medication instructions and changes in patient records

Failure to ensure individual carers read and acknowledge patient medication changes

Failure to obtain individual carers’ signed acknowledgement of patient care plans

Lack of cross-checking to prevent carers repeating inherited medication errors

Failure to procure original patient records during investigations

Unavailability of electronic access to patients’ medication histories