Concerns raised 3 Lack of safe medication storage for residents requiring supervision View source Use of untrained staff to conduct incident investigations View source Perfunctory incident investigations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Geoffrey Peter Banks · 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
Geoffrey Peter Banks, aged 64, took 44 co-codamol tablets after pulling open a locked medicine cupboard at his assisted accommodation on 1 January 2020. He was admitted to hospital and died on 8 January 2020 from an acute heart attack; the overdose contributed to his death, although it was not possible to determine whether it was accidental or deliberate. Concerns were raised about the lack of safe medication storage for residents needing supervision and about the apparent investigation being perfunctory and conducted by an untrained staff member.
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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. The report was sent to Comfort Call Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of safe medication storage for residents requiring supervision
Wider context from the report “(1) The deceased resided at Oak Priory and was the tenant of a privately rented flat in a scheme from a housing provider. He was on a care package provided by Comfort Call under a contract from Stoke on Trent Council. He received visit four times per day principally to administer medication. The medicine was kept in a locked kitchen cupboard in his flat. He had been identified as not being able to manage his own medication. The tenant was easily able to pull open the cupboard door and the barrel of the lock fell out. He overdosed on medication. There appears to be no system of safe storage in place where a resident has been identified as being in need of supervision with medication.
(2)The apparent investigation into the incident was perfunctory and carried out by an untrained member of staff.
” 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 Comfort Call Limited; that does not assign responsibility.
PFD Monitor interpretation Use of untrained staff to conduct incident investigations
Wider context from the report “(1) The deceased resided at Oak Priory and was the tenant of a privately rented flat in a scheme from a housing provider. He was on a care package provided by Comfort Call under a contract from Stoke on Trent Council. He received visit four times per day principally to administer medication. The medicine was kept in a locked kitchen cupboard in his flat. He had been identified as not being able to manage his own medication. The tenant was easily able to pull open the cupboard door and the barrel of the lock fell out. He overdosed on medication. There appears to be no system of safe storage in place where a resident has been identified as being in need of supervision with medication.
(2)The apparent investigation into the incident was perfunctory and carried out by an untrained member of staff .
” 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 Comfort Call Limited; that does not assign responsibility.
PFD Monitor interpretation Perfunctory incident investigations
Wider context from the report “(1) The deceased resided at Oak Priory and was the tenant of a privately rented flat in a scheme from a housing provider. He was on a care package provided by Comfort Call under a contract from Stoke on Trent Council. He received visit four times per day principally to administer medication. The medicine was kept in a locked kitchen cupboard in his flat. He had been identified as not being able to manage his own medication. The tenant was easily able to pull open the cupboard door and the barrel of the lock fell out. He overdosed on medication. There appears to be no system of safe storage in place where a resident has been identified as being in need of supervision with medication.
(2)The apparent investigation into the incident was perfunctory and carried out by an untrained member of staff.
” Open source 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 Communicate to Extra Care Scheme managers that they must review investigations conducted by others for adequacy.
Verbatim wording from the response “In the meantime, we will communicate to ECS managers during February 2021 that they must at the very least review investigations carried out by others at their schemes to ensure that they are adequate.” Source location 2020-0256-Response-from-Comfort-Call-Redacted.pdf
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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 Raise safeguarding concerns where individuals may be at risk from accessing their medicines.
Verbatim wording from the response “1. Raising a safeguarding concern where there is a perceived risk that an individual may be at risk from gaining access to their own medicines; and” Source location 2020-0256-Response-from-Comfort-Call-Redacted.pdf
Open published response
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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 Require Extra Care Scheme managers to review whether secure medicines storage should be raised with housing providers.
Verbatim wording from the response “Our plan for organisational learning is, therefore, to review our standard ECS protocols template to consider the question of secure medicines storage in each flat and to require all our ECS managers to undertake a review at their schemes to consider whether this issue should be raised with the housing provider. We will complete this by the end of March 2021.” Source location 2020-0256-Response-from-Comfort-Call-Redacted.pdf
Open published response
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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 standard Extra Care Scheme protocols template to consider secure medicines storage in tenants’ flats.
Verbatim wording from the response “Point 2, however, can absolutely be incorporated into our standard procedures, which include setting up written protocols with partner housing providers addressing the whole range of joint working arrangements in each ECS.” Source location 2020-0256-Response-from-Comfort-Call-Redacted.pdf
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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 care provider has no remit or capability to mandate, purchase or install secure fixtures in tenants’ flats.
Verbatim wording from the response “- Primary control of the fabric of the building, including fixtures and fittings within each tenant’s home, rests with the tenant and the housing provider, not the care provider;” Source location 2020-0256-Response-from-Comfort-Call-Redacted.pdf
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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 housing provider and commissioning authority are responsible for deciding and implementing fixture changes at the scheme.
Verbatim wording from the response “Unfortunately, as noted above, Comfort Call has no remit or capability to mandate, purchase or install fittings and fixtures in flats at Oak Priory or any other ECS. We are entirely dependent on the housing provider and commissioning authority in that regard. We could, however, at least bring our influence to bear in that regard, by:” Source location 2020-0256-Response-from-Comfort-Call-Redacted.pdf
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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 risk of medicine-related self-harm was not reasonably foreseeable because there was no previous indication of overdose, self-harm or medicine access attempts.
Verbatim wording from the response “In Mr Banks’s case, however, there were no obvious signs that the ECS was an inappropriate care setting. He had no previous history of overdose or any other form of self-harm, nor of trying to access his medicines and as such, there was no indication that he was at risk in that way. Had there been any indication that he was a danger to himself or others, we would certainly have raised this as a safeguarding matter, which may well have led to the Council considering alternative accommodation for him.” Source location 2020-0256-Response-from-Comfort-Call-Redacted.pdf
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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 Medicines could not lawfully be removed from the tenant’s flat under the provider’s care registration and the independent-living model.
Verbatim wording from the response “Whilst an ECS like Oak Priory looks superficially like a residential home, it is in fact nothing of the kind for the purposes of managing and delivering care. For example, in a residential or nursing home, medication would typically be stored and dispensed centrally by staff, and centralised records maintained. Such an arrangement at Oak Priory would clearly have prevented Mr Banks from accessing his medicines unsupervised, but it could not be done lawfully in an ECS under Comfort Call’s CQC registration because his medicines belonged to him and it was therefore required that they remain in his home (i.e. his flat).” Source location 2020-0256-Response-from-Comfort-Call-Redacted.pdf
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Concerns raised 3 Failure to complete scheduled carer visits without curtailment View source Failure to provide the assessed duration of care View source Lack of travel time allowances in carer rotas View source
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.
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AI-generated summary
Doreen Wilkins · 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
Doreen Wilkins died in hospital at age 78 after a choking incident at home following a routine care visit that did not last for its full duration. The inquest raised concerns that care-visit rotas did not allow travel time, potentially causing carers to arrive late, shorten visits, and provide less care than assessed or commissioned.
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 Comfort Call Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete scheduled carer visits without curtailment
Wider context from the report “In the course of the inquest I heard evidence to the effect that Comfort Call carers’ visits are scheduled in blocks via rotas which do not always allow for travel time between scheduled visits. The matters of concern arising from this are as follows:
1. An absence of any travel time allowance in such circumstances may cause a carer to arrive late for a time critical care visit (such as one where a client is to be supported with regular medication);
2. A carer may cut short his / her visit to one client to enable them to arrive at their next scheduled appointment on time ;
3. In circumstances where a carer is cutting short a visit, the client in question does not receive the duration of care they have been assessed as requiring (or indeed which Comfort Call Ltd has been paid to provide).
It is observed that Comfort Call Limited’s registration with the Care Quality Commission is contingent inter alia upon a requirement that the registered person must submit on the first day of every month to CQC a report showing:
“The actions that have been taken to ensure staff rotas are meeting the needs of service users including time critical calls and travel time between visits”.
” 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 Comfort Call Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the assessed duration of care
Wider context from the report “In the course of the inquest I heard evidence to the effect that Comfort Call carers’ visits are scheduled in blocks via rotas which do not always allow for travel time between scheduled visits. The matters of concern arising from this are as follows:
1. An absence of any travel time allowance in such circumstances may cause a carer to arrive late for a time critical care visit (such as one where a client is to be supported with regular medication);
2. A carer may cut short his / her visit to one client to enable them to arrive at their next scheduled appointment on time;
3. In circumstances where a carer is cutting short a visit, the client in question does not receive the duration of care they have been assessed as requiring (or indeed which Comfort Call Ltd has been paid to provide) .
It is observed that Comfort Call Limited’s registration with the Care Quality Commission is contingent inter alia upon a requirement that the registered person must submit on the first day of every month to CQC a report showing:
“The actions that have been taken to ensure staff rotas are meeting the needs of service users including time critical calls and travel time between visits”.
” 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 Comfort Call Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of travel time allowances in carer rotas
Wider context from the report “In the course of the inquest I heard evidence to the effect that Comfort Call carers’ visits are scheduled in blocks via rotas which do not always allow for travel time between scheduled visits . The matters of concern arising from this are as follows:
1. An absence of any travel time allowance in such circumstances may cause a carer to arrive late for a time critical care visit (such as one where a client is to be supported with regular medication);
2. A carer may cut short his / her visit to one client to enable them to arrive at their next scheduled appointment on time;
3. In circumstances where a carer is cutting short a visit, the client in question does not receive the duration of care they have been assessed as requiring (or indeed which Comfort Call Ltd has been paid to provide).
It is observed that Comfort Call Limited’s registration with the Care Quality Commission is contingent inter alia upon a requirement that the registered person must submit on the first day of every month to CQC a report showing:
“The actions that have been taken to ensure staff rotas are meeting the needs of service users including time critical calls and travel time between visits”.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations