Mirus WalesIncludes reports addressed to a minister or senior office-holder acting for this organisation.

Private and voluntary organisations · Care-home operator

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First report 28 Nov 2022•Latest report 28 Nov 2022

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
6

Described in responses

Concerns and recipient responses

Statements from Mirus Wales linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: The Chief Executive, MIRUS Wales.

    South Wales Central

    AI-generated summary

    Susan Jane PERRY · 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

    Susan Jane PERRY had a chronic complex mental ill health condition and was receiving long-term care and support at supported accommodation. She was found deceased in her room on 23 October 2020, and the inquest found that COVID-19 infection and elevated levels of prescription medication contributed to her death. The principal concern was that medication cupboard keys were kept nearby in unsecured locations, creating a risk that a service user could access medication; no evidence was received that practices and procedures across similar accommodation addressed this risk.

    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 Mirus Wales; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to secure medication cupboard keys

    Wider context from the report

    “(1) I received evidence from her support workers that service user's medications were kept in locked cupboards on the ground floor. However, the keys to the same were kept either in an unlocked drawer nearby, or in a pot on an adjacent, or nearby work surface. I sought clarification upon this and evidence to determine if this arrangement was still in place today. Whilst I did not receive any evidence per se on this matter, the indication I received from counsel for MIRUS Wales did not satisfy me, that arrangements for access to this cupboard had been altered or revised since Susan Perry’s death on 23.10.20. (2) My concern is simply that these arrangements give rise to a risk that a service user could access medication (their own, or other service users) from the locked cupboards by opening the same using the nearby keys, defeating the purpose of securing the medication. Deliberate, or inadvertent administration of such medication could well lead to the death of that individual. (3) I believe that MIRUS Wales operate several similar supported accommodation concerns across South Wales, and I received no evidence to satisfy me that practices & procedures were in place across these concerns to address this risk of self-harm. ”
    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 Mirus Wales; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of practices and procedures addressing self-harm risk across supported accommodation

    Wider context from the report

    “(1) I received evidence from her support workers that service user's medications were kept in locked cupboards on the ground floor. However, the keys to the same were kept either in an unlocked drawer nearby, or in a pot on an adjacent, or nearby work surface. I sought clarification upon this and evidence to determine if this arrangement was still in place today. Whilst I did not receive any evidence per se on this matter, the indication I received from counsel for MIRUS Wales did not satisfy me, that arrangements for access to this cupboard had been altered or revised since Susan Perry’s death on 23.10.20. (2) My concern is simply that these arrangements give rise to a risk that a service user could access medication (their own, or other service users) from the locked cupboards by opening the same using the nearby keys, defeating the purpose of securing the medication. Deliberate, or inadvertent administration of such medication could well lead to the death of that individual. (3) I believe that MIRUS Wales operate several similar supported accommodation concerns across South Wales, and I received no evidence to satisfy me that practices & procedures were in place across these concerns to address this risk of self-harm. ”
    Open source report

    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

    Subject the medication-safety measures to scrutiny at leadership meetings and the March 2023 Board of Trustees meeting.

    Verbatim wording from the response

    “The above measures will be subject to full scrutiny at our leadership meetings and at the next full Board of Trustee meeting in March 2023.”

    Source location

    Response from MIRUS
    Page 2 · response
    Published 28 November 2022

    Open published response

    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 medication policy and revise key-holder requirements so medication keys remain on the nominated key holder’s person.

    Verbatim wording from the response

    “• mirus has reviewed its medication policy, procedures, and practice in relation to the handling of keys. (Action completed 5th December 2022)”

    Source location

    Response from MIRUS
    Page 2 · response
    Published 28 November 2022

    Open published response

    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

    Update medication training for staff and managers to strengthen key-handling and prevent unauthorised access to medication.

    Verbatim wording from the response

    “• The content of the medication training for staff and managers has been updated to strengthen the additional measures for handling of keys to ensure safe storage and prevent unauthorised access to medication. (Action taken 5th December 2022)”

    Source location

    Response from MIRUS
    Page 2 · response
    Published 28 November 2022

    Open published response

    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

    Implement additional quality-assurance measures to verify that the medication-key and training actions have been implemented.

    Verbatim wording from the response

    “• Additional quality assurance measures will follow to ensure that the above actions have been implemented. (Action by end of February 2023)”

    Source location

    Response from MIRUS
    Page 2 · response
    Published 28 November 2022

    Open published response
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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