Waterloo Manor Independent Hospital

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First report 9 Sep 2024•Latest report 9 Sep 2024

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
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Waterloo Manor Independent Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. West Yorkshire Eastern

    AI-generated summary

    Amanda Richardson · 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

    Amanda Richardson, aged 40, was transferred from prison to a low secure mental health hospital and was found dead in her bedroom on 29 April 2023. Toxicology found a very high level of a prescribed drug, which had been prescribed at double the stipulated maximum dose, alongside evidence of illicit drug use. The concerns included inadequate medication review and monitoring, failures to record and investigate searches, and the adequacy of hospital security arrangements.

    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 Waterloo Manor Independent Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of hospital systems to review and safeguard medication prescribing and administration

    Wider context from the report

    “2. It was admitted that the prescription of ████████ at the rate of ████████mg/day was double the ████████mg/day stipulated maximum (without additional monitoring being undertaken) and was made in error. This situation went unnoticed for some six months, until her death. There was no effective system of review in the hospital in this period. The pharmacist appears to have dispensed the drug without querying the high dose. The nurses who administered the drugs did not question it. The MDT meetings which took place did not check the dose, or reflect upon its potential interaction with the several other medications prescribed. Overall, there was no effective resilience in the hospital’s systems to safeguard against drugs bring prescribed or administered in error. ”
    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 Waterloo Manor Independent Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to search patient rooms and hospital grounds after serious illicit-drug incidents

    Wider context from the report

    “4. Ms Richardson died some 9 days later. Despite the seriousness of the 19.4.23 incident, no searches were carried out in her room or the hospital grounds in the period following her return. The toxicology and pathological evidence indicated that she had taken heroin shortly before her death. Her room was not searched even after her death, as assumptions were wrongly made that her death was due to a cardiac event. ”
    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 Waterloo Manor Independent Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate security arrangements in a low secure mental health hospital

    Wider context from the report

    “6. The inquest was unable to establish how or when Ms Richardson obtained illicit illegal drugs. Concerns were expressed as to the adequacy of the security arrangements in this low secure mental health hospital as at April 2023. ”
    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 Waterloo Manor Independent Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record the nature, duration and responsible person for searches of returning patients

    Wider context from the report

    “3. On 19.4.23, Ms Richardson was permitted unescorted leave in the community under S.17 MHA 1983. She did not return. She did, however, voluntarily reappear at the hospital the following day, albeit under the influence of illicit drugs and alcohol. Evidence was given that nurses reported having searched Ms Richardson on her return, but no adequate written record was made to confirm the nature or duration of the search, nor by whom it was conducted, in breach of hospital policies. ”
    Open source report
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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