Recipient

Grassy Meadow Court

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First report 16 Aug 2021•Latest report 16 Aug 2021

Recipient record

Reports, concerns and published responses

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

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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 Grassy Meadow Court linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. West London

    AI-generated summary

    Kumbulani MTOMBENI · 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

    Kumbulani Mtombeni was found deceased at his home on 25 January 2021, with evidence indicating that he intended to take his own life; the inquest conclusion was suicide and the recorded cause of death was methadone toxicity. The principal concerns were how methadone prescribed to another person came into his possession, whether medication audits identified missing medication, and his access to residents’ prescribed medicines through his work as a senior carer.

    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 Grassy Meadow Court; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to control staff access to residents' prescribed medication

    Wider context from the report

    “In the deceased's possession was a ████████ of methadone in the name of ████████. Evidence was given at inquest that Mr ████████ was one of your residents until he died last summer. Mr Mtombeni was a member of your staff and at times had worked as a senior carer and had responsibility for and access to the residents prescribed medications. (1) Can you explain how the methadone was in Mr Mtombeni's possession? (2) Were any audits performed that demonstrated missing medication and if so, what actions were taken? (3) What actions will now be taken in the light of the findings at inquest? ”
    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 Grassy Meadow Court; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to audit for missing medication

    Wider context from the report

    “In the deceased's possession was a ████████ of methadone in the name of ████████. Evidence was given at inquest that Mr ████████ was one of your residents until he died last summer. Mr Mtombeni was a member of your staff and at times had worked as a senior carer and had responsibility for and access to the residents prescribed medications. (1) Can you explain how the methadone was in Mr Mtombeni's possession? (2) Were any audits performed that demonstrated missing medication and if so, what actions were taken? (3) What actions will now be taken in the light of the findings at inquest? ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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