Concerns raised 9 Inadequate and unsafe medicine administration training, supervision and audit processes View source Inadequate and unsafe medicines policy View source Inadequate and incomplete record keeping View source Inadequate pre-admission assessment of care needs View source Lack of a policy or protocol for observation and monitoring of service users View source Failure to recognise deteriorating service users View source Inadequate pre-admission risk assessment View source Delays in seeking medical attention when service users deteriorate View source Insufficient communication and handover during transfers of care View source See 6 more concerns
Responses linked to these concerns
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AI-generated summary
Dr Donald Clegg · 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
Dr Donald Clegg, who had complex physical and mental health needs, was transferred to a short-term residential placement that was unable to manage his care needs. Concerns included inadequate assessment and communication during the transfer, unsafe medication management, insufficient monitoring, delayed recognition of deterioration and inadequate record keeping. He developed breathing difficulties and seizure-like activity on 26 February 2018, was admitted to hospital and died later that day; the stated cause of death was acute left ventricular heart failure due to severe ischaemic heart disease and left ventricular hypertrophy.
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 Persona Care And Support Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate and unsafe medicine administration training, supervision and audit processes
Wider context from the report “3. The evidence indicated that the:
i) Medicine Policy
&/or
ii)Medicine administration training, supervision and audit processes
at Persona were inadequate and unsafe (indeed, the audit process was perfunctory ).
” 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 Persona Care And Support Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate and unsafe medicines policy
Wider context from the report “3. The evidence indicated that the:
i) Medicine Policy
&/or
ii)Medicine administration training, supervision and audit processes
at Persona were inadequate and unsafe (indeed, the audit process was perfunctory).
” 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 Persona Care And Support Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate and incomplete record keeping
Wider context from the report “5. Record keeping was inadequate and in parts, incomplete . Record keeping is vital in keeping service users safe.
” 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 Persona Care And Support Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate pre-admission assessment of care needs
Wider context from the report “Persona Only:
2. The process of assessment of care needs prior to admission was inadequate . Assessment is critical in establishing the suitability and safety of a placement – in this case, capable of meeting complex physical and mental health needs of the individual. Assessment of risk, in particular, was inadequate.
” 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 Persona Care And Support Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy or protocol for observation and monitoring of service users
Wider context from the report “6. There is no policy/protocol for the observation/monitoring of service users e.g. when directed to do so by a medical practitioner. Staff are left to interpret for themselves what this means .
” 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 Persona Care And Support Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deteriorating service users
Wider context from the report “4. Staff were unable to recognise the deteriorating adult and did not seek medical attention in a timely manner when signs of change became apparent. This potentially puts service users at risk of harm/death.
” 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 Persona Care And Support Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate pre-admission risk assessment
Wider context from the report “Persona Only:
2. The process of assessment of care needs prior to admission was inadequate. Assessment is critical in establishing the suitability and safety of a placement – in this case, capable of meeting complex physical and mental health needs of the individual. Assessment of risk, in particular, was inadequate .
” 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 Persona Care And Support Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in seeking medical attention when service users deteriorate
Wider context from the report “4. Staff were unable to recognise the deteriorating adult and did not seek medical attention in a timely manner when signs of change became apparent . This potentially puts service users at risk of harm/death.
” 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 Persona Care And Support Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication and handover during transfers of care
Wider context from the report “Persona and Bury MBC:
1. Communication/transfer of care/handover between social services, the first placement and/or the final placement was insufficient , given the complexities of the deceased’s case.
” 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 Review and amend the medication policy, including visual one-page guides for key aspects.
Verbatim wording from the response “Investment in an Electronic Medication Administration System (EMAR) which is designed to improve accuracy and safety in respect of medication administration whilst also improving audit trails. This is being implemented at Elmhurst this week (w/c 24/9/18) and will be rolled out to our other short stay unit Spurr House in October 2018.
3b. On-going exceptional Board reporting on medication errors and progress against the medication action plan.
3c. Review and amendment of the medication policy to make it clearer for staff and to develop visual one page guides on certain key aspects of the policy.
3d. Review of our current medication training which we felt could be improved. We have therefore sourced an additional detailed and assessed training package which will be rolled out to staff imminently.
3e. Review and amendment of the self-administration assessments and protocols.” Source location 2018-0269-Response-by-Persona
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 Implement and embed the electronic care-planning system to improve real-time recording and structured care documentation.
Verbatim wording from the response “5. Record keeping was inadequate and in parts incomplete
Record keeping in social care has become an increasingly significant part of the role in recent years and as a result during 2017 we investigated a number of electronic care planning systems and in autumn 2017 purchased and began implementation of our chosen system Access Mobizio. Roll-out to Elmhurst took place in February 2018. It is now the case that all care planning is in the majority digital within short stay. The system allows real time recording, voice recording and more structured prompts which all contribute to improved record keeping. The QA Framework includes audits and spot checks of care records to assess the quality and accuracy of these. We have identified that there is still further work to do with staff to continue to embed the approach and to drive a culture of improved record keeping.” Source location 2018-0269-Response-by-Persona
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 Include Persona representatives in multidisciplinary meetings for transfers between Killelea and Persona services.
Verbatim wording from the response “1. Communication and transfer of care between social services, the first placement and the final placement
The comments raised relate to the inadequate communication between the care teams at Killelea (Bury Council) and Elmhurst (Persona), particularly given the complexities of Dr Clegg’s circumstances.
A meeting has now taken place between the Persona Operations Director and the Business Manager responsible for Intermediate Managed Care at Bury Council. It has been agreed that going forward and with immediate effect where a customer is being discharged from Killelea to Persona services, or vice versa, a representative from Persona will be included in a multi-disciplinary team meeting with the appropriate health professionals.” Source location 2018-0269-Response-by-Persona
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 Complete and roll out the comprehensive quality assurance framework for meaningful, signed-off audits and organisational improvement plans.
Verbatim wording from the response “These now include a requirement to count medication weekly for people who are self-administering, and a mapping tool to allow the amount actually taken to be tracked against that which should have been consumed.
3f. Development of a comprehensive quality assurance framework (QA Framework). This has been completed in partnership with an external consultant. The work on the QA Framework has drawn current audit tools together to ensure that they are fit for purpose and all audits are meaningful, signed off by a more senior manager, and any actions are captured at a scheme and organisational level in an Improvement Plan. This work has taken place across the summer months and is currently being rolled out in” Source location 2018-0269-Response-by-Persona
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 Pilot a Medication Co-ordinator role providing specialist medication support, pharmacy and GP liaison, and auditing capacity.
Verbatim wording from the response “short stay during September and early October. We will work hard as a team to ensure it is embedded throughout the organisation.
3g. As medication in short stay services is particularly complex and busy we have reviewed the structure and are currently piloting having a Medication Co-ordinator role to provide more specialist knowledge and support in this area, as well as additional skilled capacity to undertake pharmacy and GP liaison and auditing.
3h. Review of the skills required by staff who administer medication has identified that there are skills around numeracy and attention to detail which had been underestimated in the previous job description and core attributes. These have now been added to job descriptions and will form part of the recruitment assessment in the future.
3i.” Source location 2018-0269-Response-by-Persona
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 Amend self-administration assessments and protocols to require weekly medication counts and track actual consumption against expected consumption.
Verbatim wording from the response “Investment in an Electronic Medication Administration System (EMAR) which is designed to improve accuracy and safety in respect of medication administration whilst also improving audit trails. This is being implemented at Elmhurst this week (w/c 24/9/18) and will be rolled out to our other short stay unit Spurr House in October 2018.
3b. On-going exceptional Board reporting on medication errors and progress against the medication action plan.
3c. Review and amendment of the medication policy to make it clearer for staff and to develop visual one page guides on certain key aspects of the policy.
3d. Review of our current medication training which we felt could be improved. We have therefore sourced an additional detailed and assessed training package which will be rolled out to staff imminently.
3e. Review and amendment of the self-administration assessments and protocols.” Source location 2018-0269-Response-by-Persona
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 develop training to help staff recognise deterioration, question medical professionals, and identify triggers for seeking further advice.
Verbatim wording from the response “4. Staff were unable to recognise the signs of deterioration and did not seek medical attention in a timely manner
This finding is one which we have reflected on at some length. As you will be aware, Elmhurst does not hold a Nursing registration and the staff we employ are social care staff and not medically qualified. Therefore the monitoring that we undertake when someone is unwell needs to be appropriate to the specifics of our registration. Having reflected and reviewed our approach I believe that this service would benefit from additional training and we also need to empower staff to ask more and better questions of medical professionals in order to understand what to expect, and what triggers to look for in an individual’s specific case in order to know when to seek further advice or involve medical professionals.” Source location 2018-0269-Response-by-Persona
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 Roll out the sourced detailed, assessed medication training package to staff.
Verbatim wording from the response “Investment in an Electronic Medication Administration System (EMAR) which is designed to improve accuracy and safety in respect of medication administration whilst also improving audit trails. This is being implemented at Elmhurst this week (w/c 24/9/18) and will be rolled out to our other short stay unit Spurr House in October 2018.
3b. On-going exceptional Board reporting on medication errors and progress against the medication action plan.
3c. Review and amendment of the medication policy to make it clearer for staff and to develop visual one page guides on certain key aspects of the policy.
3d. Review of our current medication training which we felt could be improved. We have therefore sourced an additional detailed and assessed training package which will be rolled out to staff imminently.
3e. Review and amendment of the self-administration assessments and protocols.” Source location 2018-0269-Response-by-Persona
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 Monitor transfer meetings and assess whether further communication methods are needed.
Verbatim wording from the response “I will ensure that this is monitored to see how it works in practice and whether we need to review additional methods to ensure we have the right level of communications between the respective teams.” Source location 2018-0269-Response-by-Persona
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 Implement an electronic medication administration system at Elmhurst and roll it out to Spurr House.
Verbatim wording from the response “Investment in an Electronic Medication Administration System (EMAR) which is designed to improve accuracy and safety in respect of medication administration whilst also improving audit trails. This is being implemented at Elmhurst this week (w/c 24/9/18) and will be rolled out to our other short stay unit Spurr House in October 2018.
3b. On-going exceptional Board reporting on medication errors and progress against the medication action plan.
3c. Review and amendment of the medication policy to make it clearer for staff and to develop visual one page guides on certain key aspects of the policy.
3d. Review of our current medication training which we felt could be improved. We have therefore sourced an additional detailed and assessed training package which will be rolled out to staff imminently.
3e. Review and amendment of the self-administration assessments and protocols.” Source location 2018-0269-Response-by-Persona
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 a simple observation protocol and recording system for monitoring service users when directed by medical practitioners.
Verbatim wording from the response “Having reviewed this area, we do not have an adequate system and protocol. This links closely to Point 4 (above). We will be developing a simple protocol for staff and an appropriate recording system for observations to sit alongside the training mentioned earlier. The new Compliance Manager will be tasked with this as an urgent action.” Source location 2018-0269-Response-by-Persona
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 Recruit and appoint a Compliance Manager responsible for medication auditing.
Verbatim wording from the response “Focus groups with staff are due to take place in early October 2018 to understand the challenges that they see in administering medication and any solutions which they feel would improve their ability to perform consistently well in this area. We are also talking to other service providers to look at sharing best practice tips and tools.
3j. In addition we have recruited a Compliance Manager (this is a senior appointment) who will be responsible for auditing medication. This post reports directly to me as the Managing Director. The post-holder commences on 1 October 2018.” Source location 2018-0269-Response-by-Persona
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 Establish an additional short-stay admissions post to obtain detailed referral information and support face-to-face assessments or multidisciplinary meetings.
Verbatim wording from the response “In light of the findings from this inquest we have reviewed the assessment process and we will be enhancing our approach to admissions. This involves the establishment of an additional post within our short stay services which will focus on admissions, ensuring that we obtain detailed information for the Registered Manager to allow them to make an informed judgement. This will also provide capacity for a face to face assessment or involvement in multi-disciplinary team meetings (as described at point 1) as required.” Source location 2018-0269-Response-by-Persona
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 Monitoring of unwell service users is limited to what is appropriate for Elmhurst’s social-care registration and staff’s non-medical qualifications.
Verbatim wording from the response “4. Staff were unable to recognise the signs of deterioration and did not seek medical attention in a timely manner
This finding is one which we have reflected on at some length. As you will be aware, Elmhurst does not hold a Nursing registration and the staff we employ are social care staff and not medically qualified. Therefore the monitoring that we undertake when someone is unwell needs to be appropriate to the specifics of our registration. Having reflected and reviewed our approach I believe that this service would benefit from additional training and we also need to empower staff to ask more and better questions of medical professionals in order to understand what to expect, and what triggers to look for in an individual’s specific case in order to know when to seek further advice or involve medical professionals.” Source location 2018-0269-Response-by-Persona
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