PFD report

Tracy Marie BROWN · Prevention of Future Deaths report

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Issued 8 Dec 2022•Hampshire, Portsmouth and Southampton

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to include medication security instructions in the digital application used by carers
    Part of recurring concern: Failure to secure and control medication
  2. Failure to keep medication in a locked box
    Part of recurring concern: Failure to secure and control medication
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Add medication administration and storage instructions to care plans and prevent plans being issued without this task.

    Stated by APEX Prime CareStated completedThe respondent said that this action was complete when they made their response on 9 December 2022.
  2. Action

    Reassess service users’ locked medication storage and require sufficient capacity for all medication without storing other medication in the property.

    Stated by APEX Prime CareStated completedThe respondent said that this action was complete when they made their response on 9 December 2022.
  3. Action

    Update the medication policy to cover medication storage and locked boxes.

    Stated by APEX Prime CareStated completedThe respondent said that this action was complete when they made their response on 9 December 2022.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to include medication security instructions in the digital application used by carers

Wider context from the report

“I heard evidence that medication for Ms Brown was required to be kept in a locked box due to a risk of her not taking the correct amount or taking too much medication. This was since Apex Care became involved in her care in March 2021. Despite this identified risk staff left regularly a nomad box containing a week's worth of medication unsecured in her kitchen cupboard. On the digital application used to inform carers of what medication to administer, which was used by the carers daily, there was no reference to keeping the medication in the secure box. ”

Is this part of a recurring concern?

Yes — Failure to secure and control medication.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to keep medication in a locked box

Wider context from the report

“I heard evidence that medication for Ms Brown was required to be kept in a locked box due to a risk of her not taking the correct amount or taking too much medication. This was since Apex Care became involved in her care in March 2021. Despite this identified risk staff left regularly a nomad box containing a week's worth of medication unsecured in her kitchen cupboard. On the digital application used to inform carers of what medication to administer, which was used by the carers daily, there was no reference to keeping the medication in the secure box. ”

Is this part of a recurring concern?

Yes — Failure to secure and control medication.

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

Add medication administration and storage instructions to care plans and prevent plans being issued without this task.

Verbatim wording from the response

“There is a task on the care plan of how medication is to be given and where it is stored but, on this occasion, it wasn’t which I should have picked up when I audited the care plan before going into the service user’s property. I have learnt a valuable lesson and I have filtered this down to all my office staff and no care plans go out without this task in place.”

Source location

Response from APEX Prime Care
Page 2 · response
Published 9 December 2022

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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

Reassess service users’ locked medication storage and require sufficient capacity for all medication without storing other medication in the property.

Verbatim wording from the response

“Since the passing of TB Apex Prime Care have learnt valuable lessons with reference to medication, we quickly reassessed every service user that has medication in a locked box to store medication. There now must be room to place all medication in the locked box with no other medication stored in the property. Some service users have had to purchase 2 locked boxes to fit all the medication in or a safe. If the delivery is weekly only, when we do the assessment, we are reiterate to the service user or their families not to buy over the counter medication as we are unable to monitor this closely and are unaware of what the service user is taking.”

Source location

Response from APEX Prime Care
Page 2 · response
Published 9 December 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 the medication policy to cover medication storage and locked boxes.

Verbatim wording from the response

“Apex Prime Care has also changed their medication policy to reflect medication and locked boxes (I have included the new updated policy and highlighted in yellow the changes to the policy).”

Source location

Response from APEX Prime Care
Page 2 · response
Published 9 December 2022

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Advise service users and families not to purchase over-the-counter medication that staff cannot monitor.

    Stated by APEX Prime CareStated completedThe respondent said that this action was complete when they made their response on 9 December 2022.

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

Advise service users and families not to purchase over-the-counter medication that staff cannot monitor.

Verbatim wording from the response

“Since the passing of TB Apex Prime Care have learnt valuable lessons with reference to medication, we quickly reassessed every service user that has medication in a locked box to store medication. There now must be room to place all medication in the locked box with no other medication stored in the property. Some service users have had to purchase 2 locked boxes to fit all the medication in or a safe. If the delivery is weekly only, when we do the assessment, we are reiterate to the service user or their families not to buy over the counter medication as we are unable to monitor this closely and are unaware of what the service user is taking.”

Source location

Response from APEX Prime Care
Page 2 · response
Published 9 December 2022

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026