PFD report

Elaine Rose Renshaw · Prevention of Future Deaths report

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Issued 25 Feb 2020•Manchester South

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
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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

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Concerns raised2

  1. Failure of controlled drug checks to identify unaccounted drugs
    Part of recurring concern: Unreliable controlled-drug custody, documentation and audit controlsPart of recurring concern: Unsafe medication administration
  2. Lack of a clear process for handling and recording controlled drug use
    Part of recurring concern: Unreliable controlled-drug custody, documentation and audit controls
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 of controlled drug checks to identify unaccounted drugs

Wider context from the report

“During the course of the inquest evidence was given that controlled drug checks processes had been such that it was not easily identified that drugs were not accounted for e.g. Stock sheets were inaccurate. The home in question had tightened up its processes since the incident. However the inquest heard that this issue may well arise in the future in other care/nursing home settings as there is no clear process for handling/recording the use of controlled drugs. ”

Is this part of a recurring concern?

Yes — Unreliable controlled-drug custody, documentation and audit controls; Unsafe medication administration.

Open source report

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

Lack of a clear process for handling and recording controlled drug use

Wider context from the report

“During the course of the inquest evidence was given that controlled drug checks processes had been such that it was not easily identified that drugs were not accounted for e.g. Stock sheets were inaccurate. The home in question had tightened up its processes since the incident. However the inquest heard that this issue may well arise in the future in other care/nursing home settings as there is no clear process for handling/recording the use of controlled drugs. ”

Is this part of a recurring concern?

Yes — Unreliable controlled-drug custody, documentation and audit controls.

Open source report
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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