Richard Philip WHITE · Prevention of Future Deaths report

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Issued 28 Feb 2014•County Durham and Darlington

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

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 raised3

  1. Failure to provide the medication administration and holding policy in a protocol or policy statement to relevant staff
    Part of recurring concern: Unreliable staff access to and understanding of safety-critical guidancePart of recurring concern: Unsafe medication administration
  2. Failure to make the medication administration and holding policy known to prescribers
    Part of recurring concern: Unreliable medication management in care homesPart of recurring concern: Unsafe medication administration
  3. Unavailability of a protocol or policy statement on medication administration and holding
    Part of recurring concern: Unsafe medication administration

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. 700 Club

    Follow a medication-surrender procedure requiring prescribing-GP authority before return and referral to a chemist when authority is declined.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. 700 Club

    Responsibility for safeguarding clients regarding prescribed medication lies with GPs, not the organisation.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 provide the medication administration and holding policy in a protocol or policy statement to relevant staff

Wider context from the report

“1) That the policy of Hope House with regard to the administration and holding by staff of medication was not made known to ████████ when she wrote the prescriptions; 2) That the policy was not provided in a protocol, or policy statement, to ████████, or indeed, ████████ and ████████ 3) That no such protocol or policy statement was available. ”

Is this part of a recurring concern?

Yes — Unreliable staff access to and understanding of safety-critical guidance; 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

Failure to make the medication administration and holding policy known to prescribers

Wider context from the report

“1) That the policy of Hope House with regard to the administration and holding by staff of medication was not made known to ████████ when she wrote the prescriptions; 2) That the policy was not provided in a protocol, or policy statement, to ████████, or indeed, ████████ and ████████ 3) That no such protocol or policy statement was available. ”

Is this part of a recurring concern?

Yes — Unreliable medication management in care homes; 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

Unavailability of a protocol or policy statement on medication administration and holding

Wider context from the report

“1) That the policy of Hope House with regard to the administration and holding by staff of medication was not made known to ████████ when she wrote the prescriptions; 2) That the policy was not provided in a protocol, or policy statement, to ████████, or indeed, ████████ and ████████ 3) That no such protocol or policy statement was available. ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

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

Follow a medication-surrender procedure requiring prescribing-GP authority before return and referral to a chemist when authority is declined.

Verbatim wording from the response

“Occasionally a client will hand their medication to us because they feel tempted to take more than prescribed. If this does occur, we will receive it but will not return the medication to the client without the direct authority of the prescribing GP. Where that authority is provided, all of the surrendered medication will be handed back to the client, and not merely sufficient medication for any particular dose or day. Again, I reiterate, we do not administer. If the GP declines to give consent for all of the medication to be returned to the client then staff are instructed to return the medication to the nearest chemist and direct their client back to their GP.”

Source location

2014-0085-Response-by-700-Club2
Page 1 · response
Published 28 February 2014

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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

Responsibility for safeguarding clients regarding prescribed medication lies with GPs, not the organisation.

Verbatim wording from the response

“I am writing to your practice on behalf of the 700 Club to remove any ambiguity relating to the storage or administration of medication by our organization. We do not, as a matter of policy, either store medication on behalf of our clients, nor do we administer medication to clients. Prescriptions issued to our clients by your practice should take the above information into account, particularly if that client is vulnerable and there is a concern that the client may use that medication inappropriately (self-harm, selling on). The responsibility for safeguarding clients in regard to prescribed medication lies with GP's.”

Source location

2014-0085-Response-by-700-Club2
Page 1 · response
Published 28 February 2014

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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