Recipient

Passmonds House Care Home

First report 10 Mar 2014•Latest report 10 Mar 2014

Recipient record

Reports, concerns and published responses

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

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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 Passmonds House Care Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

10 Mar2014
Manchester North
Concerns raised7
1. Failure of the drugs administration policy to meet pharmacy requirements for patient and drug identification
2. Failure of care home management to identify carers’ non-compliance with drugs administration protocols
3. Failure of inspections to identify inadequacies in the drugs policy and drug administration protocol
1. Failure to act upon all post-event recommendations in a timely manner
2. Incomplete inspection of CQC Outcomes and the drugs administration system
3. Lack of care home audit processes
4. Failure of the drugs administration protocol to be fit for purpose and specific to the care home environment
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.
AI-generated summary

Derrick George RIVERS · 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

Derrick George Rivers, who had been admitted to full-time care after becoming frail and falling, was mistakenly given a 150mg dose of Clozapine intended for another resident. He was admitted to hospital with altered consciousness and confusion, initially improved, then deteriorated and died on 11 July 2013; the inquest found that he died from natural causes to which the Clozapine may have contributed. Concerns included inadequate medication policies and administration protocols, insufficient auditing and inspection, and incomplete implementation of recommendations intended to reduce the risk of medication errors.

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 Passmonds House Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of the drugs administration policy to meet pharmacy requirements for patient and drug identification
Wider context from the report
“6) That the care home’s policy did not meet the pharmacy requirements in terms of patient and drug identification (pod system). ”
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 Passmonds House Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of care home management to identify carers’ non-compliance with drugs administration protocols
Wider context from the report
“3) That the care home owner and/or manager were purportedly unaware of the fact that carers were not following drugs administration protocols. ”
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 Passmonds House Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of inspections to identify inadequacies in the drugs policy and drug administration protocol
Wider context from the report
“1) That the Local Authority and/or CQC, following their recent inspections of the care home, had not noted the inadequacies of the care home’s drugs policy/drug administration protocol. ”
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 Passmonds House Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to act upon all post-event recommendations in a timely manner
Wider context from the report
“7) That the care home owner and/or manager did not act upon all recommendations made by ████████ after the event, in a timely manner. Risks therefore remain. ”
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 Passmonds House Care Home; that does not assign responsibility.
PFD Monitor interpretation
Incomplete inspection of CQC Outcomes and the drugs administration system
Wider context from the report
“2) That not all CQC Outcomes were considered at the last inspection, purportedly because they did not have anyone available to inspect and review the drugs administration system at the material time. ”
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 Passmonds House Care Home; that does not assign responsibility.
PFD Monitor interpretation
Lack of care home audit processes
Wider context from the report
“4) That the care home had little, if any, audit processes in place. ”
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 Passmonds House Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of the drugs administration protocol to be fit for purpose and specific to the care home environment
Wider context from the report
“5) That the care home’s drugs administration protocol was not fit for purpose and was tantamount to a ‘hybrid’ of other policies i.e. it was not specific to the care home environment. ”
Open source report

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 raised7

Failure of the drugs administration policy to meet pharmacy requirements for patient and drug identification

Failure of care home management to identify carers’ non-compliance with drugs administration protocols

Failure of inspections to identify inadequacies in the drugs policy and drug administration protocol

Failure to act upon all post-event recommendations in a timely manner

Incomplete inspection of CQC Outcomes and the drugs administration system

Lack of care home audit processes

Failure of the drugs administration protocol to be fit for purpose and specific to the care home environment