Concerns raised 1 Failure to have a safeguarding policy and process for acting on resident risk without relying solely on consent View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 7
Action
Continue consulting mental health, pharmacy and substance-misuse agencies on safeguarding responses to medication stockpiling.
View source
Action
Review and refresh the LIFE support practice model to strengthen risk assessment and management for people at risk of self-harm or suicide.
View source
Action
Develop and pilot a medication-stockpiling risk-assessment checklist with accompanying staff guidance and training.
View source
Action
Use manager oversight and quality-assurance review to document and follow up staff concerns recorded through the medication-stockpiling checklist.
View source
Action
Review and update risk-assessment templates, risk-management plans, training resources and quality-assurance checks for medication-stockpiling concerns.
View source
Action
Review the Tenure Policy, including standards governing house rules and room access in suspected medication-stockpiling situations.
View source
Action
Review and update the Support Practice Policy, consulting customers, partner agencies and stakeholders and considering inquest learning on risk management.
View source See 4 more actions
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AI-generated summary
Christopher John O’Donnell · 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
Christopher John O’Donnell died on 12 December 2023 in supported living accommodation after taking a substantial amount of methadone, vomiting and suffering airway obstruction by vomit. The principal concern was that excess medication remained within his control despite recognised risks, with no apparent basis or consideration for the accommodation provider to remove it as a safeguarding measure during a mental health crisis.
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 Home Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to have a safeguarding policy and process for acting on resident risk without relying solely on consent
Wider context from the report “The issue that I had was that there appeared to be no basis for or consideration of the supported living accommodation provider, taking action to provide safeguarding for Christopher by removing the excess medication so that it was not within his control . I was informed by ████████ that the supported living accommodation provider did not show staff to hold any medication even if it was done with the intention of providing safeguarding to someone, who by all accounts, was undergoing a mental health crisis .
I would hope that the organisation will review its policies as to what action (if any) it can take when it is made aware of a risk to a resident, rather than to only take action with the resident’s consent .
” 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 Continue consulting mental health, pharmacy and substance-misuse agencies on safeguarding responses to medication stockpiling.
Verbatim wording from the response “Home Group are committed to working in partnership with key agencies to mitigate the risks associated with the stockpiling of prescribed medication in supported housing settings, within the limits of what is legally permissible and within our service remit.” Source location Response from Home Group Limited
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 and refresh the LIFE support practice model to strengthen risk assessment and management for people at risk of self-harm or suicide.
Verbatim wording from the response “We are currently in the process of reviewing and refreshing our LIFE support practice model to ensure that it is effective in facilitating compliance with the practice standards set out in the Support Practice Policy. Our review is focussed on strengthening our approach to risk assessment and risk management, especially when working with individuals thought to be at risk of self-harm or suicide.” Source location Response from Home Group Limited
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 Develop and pilot a medication-stockpiling risk-assessment checklist with accompanying staff guidance and training.
Verbatim wording from the response “It was agreed with CGL that as part of expectations moving forward, any concerns regarding the stockpiling of medication by a service user will be reported by Home Group directly to the relevant local pharmacy who can then either arrange for the collection of the medication or instruct CGL to manage removal. We also agreed that matters concerning the stockpiling of medication should be dealt with at manager rather than support worker level, and that the guidance for support workers will be to escalate any concerns to management. To support this, we are looking to implement a risk assessment checklist as a useful resource for support workers. This checklist is addressed in more detail below.” Source location Response from Home Group Limited
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 Use manager oversight and quality-assurance review to document and follow up staff concerns recorded through the medication-stockpiling checklist.
Verbatim wording from the response “Where there is evidence that a customer is stockpiling medication, the checklist alerts staff to discussing this as a safeguarding risk with partner agencies, including the prescriber and relevant pharmacy. Managers will have oversight of the checklist as part of our quality assurance approach. Staff are required to review the checklist with their manager and to document what was discussed and any actions agreed.” Source location Response from Home Group Limited
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 and update risk-assessment templates, risk-management plans, training resources and quality-assurance checks for medication-stockpiling concerns.
Verbatim wording from the response “As part of Home Group’s wider planned policy review, we plan to review and update risk assessment templates and risk management plans, alongside training resources and quality assurance checks, to support accurate and timely risk management where there are concerns in relation to stockpiling medication.” Source location Response from Home Group Limited
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 Tenure Policy, including standards governing house rules and room access in suspected medication-stockpiling situations.
Verbatim wording from the response “We are also planning to carry out a concurrent review of our Tenure Policy, which includes standards around the enforcement of tenancy terms and conditions.” Source location Response from Home Group Limited
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 and update the Support Practice Policy, consulting customers, partner agencies and stakeholders and considering inquest learning on risk management.
Verbatim wording from the response “b) Planned policy review” Source location Response from Home Group Limited
Open published response
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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 Where a service user has capacity, medication cannot be removed without authority, and controlled drugs cannot lawfully be retained or stored on the premises.
Verbatim wording from the response “As detailed in your PFDR, we understand that you are concerned that action was not taken by Home Group in removing stockpiled medication from Mr O’Donnell’s room in circumstances where concerns had been raised both internally and externally that he was stockpiling prescribed medication.” Source location Response from Home Group Limited
Open published response
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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 Responsibility for handling or administering medication in these services lies with Change Grow Live, not the supported housing provider.
Verbatim wording from the response “Home Group’s services in the Swindon area, encompassing Canal House, are not commissioned by the local authority to provide support to service users in relation to the handling or administering of medication. In this situation, the responsibility for this would lie with Change Grow Live (“CGL”).” Source location Response from Home Group Limited
Open published response
9 Oct 2014 Stephen Peter Simpson · Prevention of Future Deaths report North Northumberland
View report summary
Concerns raised 2 Lack of an entrance lobby or passageway to arrest falls from communal stairs View source Lack of a non-slip surface on communal stairs View source
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
Stephen Peter Simpson · 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
Stephen Peter Simpson appears to have fallen down communal concrete stairs on 13 March 2014 and struck his head on an external door, later dying in hospital from a skull fracture and brain haemorrhage. The concerns were that the building had no lobby or passageway to arrest a fall and that the smooth concrete stairs lacked a non-slip surface, leaving a risk of serious injury or death from impact with the door.
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 Home Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of an entrance lobby or passageway to arrest falls from communal stairs
Wider context from the report “The design of the building is that there is no entrance lobby or passageway to arrest any accidental fall , with the result that any person who slips or falls while negotiating the communal stairs is liable to sustain serious injury from making impact with the solid external door . Additionally, the stairs are constructed of smooth concrete without the addition of any non-slip surface. Even if a non-slip surface was present, this would not obviate the risk of serious injury or death from impact with the external door, if a person falls from the stairs.
” 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 Home Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a non-slip surface on communal stairs
Wider context from the report “The design of the building is that there is no entrance lobby or passageway to arrest any accidental fall, with the result that any person who slips or falls while negotiating the communal stairs is liable to sustain serious injury from making impact with the solid external door. Additionally, the stairs are constructed of smooth concrete without the addition of any non-slip surface . Even if a non-slip surface was present, this would not obviate the risk of serious injury or death from impact with the external door, if a person falls from the stairs.
” 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