Recipient

Mirus Wales

First report 28 Nov 2022•Latest report 28 Nov 2022

Recipient record

Reports, concerns and published responses

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

Reports: 1
Published responses: 100%
Concerns addressed: 1
Stated actions: 6

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.

100%published responses found

6stated actions described

Topic comparisons are not available in the current evidence snapshot.

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.

28 Nov2022
South Wales Central
Concerns raised2
1. Failure to secure medication cupboard keys
2. Lack of practices and procedures addressing self-harm risk across supported accommodation
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Subject the medication-safety measures to scrutiny at leadership meetings and the March 2023 Board of Trustees meeting.
  Stated planned
2. Action
  Review the medication policy and revise key-holder requirements so medication keys remain on the nominated key holder’s person.
  Stated completed
3. Action
  Update medication training for staff and managers to strengthen key-handling and prevent unauthorised access to medication.
  Stated completed
1. Action
  Implement additional quality-assurance measures to verify that the medication-key and training actions have been implemented.
  Stated planned
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

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 raised2

Failure to secure medication cupboard keys

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

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.4

Actions described in response 4