PFD report

Leonardus Adrianus VRIES · Prevention of Future Deaths report

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Issued 9 Mar 2015•Worcestershire

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.

View original report
Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in 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.

Report evidence summary

Concerns raised1

  1. Failure to audit and track the use of non-controlled medication
    Part of recurring concern: Failure of care and safety auditing to identify deficienciesPart 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

    Continue monitoring drug-usage trends across all Trust areas to identify potential diversion risks.

    Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2015.
  2. Action

    Conduct unannounced spot audits of theatre drug storage and documentation.

    Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2015.
  3. Action

    Review controls governing controlled and non-controlled medicines.

    Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2015.

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

  1. Position

    Existing controls and professional responsibilities are considered sufficient to mitigate the small residual risk of medicine diversion.

    Stated by the Royal Orthopaedic Hospital NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 audit and track the use of non-controlled medication

Wider context from the report

“Whilst the control of controlled medications appears to have been addressed by way of training and increased scrutiny and audit procedures ████████ confirms that there is still no audit of non-controlled medication. Specifically he said that when stocks of non-controlled medication are delivered to wards and departments there is no check as to who uses the medication or for what purpose. It appears to me therefore that there is a significant opportunity for the abuse or theft of non-controlled medication. ”

Is this part of a recurring concern?

Yes — Failure of care and safety auditing to identify deficiencies; Failure to secure and control medication.

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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

Continue monitoring drug-usage trends across all Trust areas to identify potential diversion risks.

Verbatim wording from the response

“this risk the Chief Pharmacist will continue to monitor trends in usage of drugs in all areas of the Trust.”

Source location

2015-0088-Response-by-Royal-Orthopaedic-Hospital
Page 3 · response
Published 9 March 2015

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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

Conduct unannounced spot audits of theatre drug storage and documentation.

Verbatim wording from the response

“Since February 2015 a weekly audit of Controlled Drug documentation is carried out by theatres management. Since March 2015 the Chief Pharmacist has carried out unannounced spot audits (normally two per week) on drug storage (all drugs) and documentation in theatres. No concerns regarding diversion or theft of medicines have been identified through this audit cycle and all documentation is correctly completed.”

Source location

2015-0088-Response-by-Royal-Orthopaedic-Hospital
Page 2 · response
Published 9 March 2015

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

Review controls governing controlled and non-controlled medicines.

Verbatim wording from the response

“In summary, the controls around both Controlled Drugs and “non-controlled” drugs have been reviewed. Standard Operating Procedures for Controlled Drugs have been updated and audits conducted by the Chief Pharmacist have shown compliance with the standards required. Controls around “non-controlled” medicines have been reviewed and found to be compliant with or indeed exceed all national guidance. There remains a small risk that these medicines could be diverted as is the case in all hospitals. This is mitigated by the professional responsibilities of all staff regarding the use of medicines. To further mitigate”

Source location

2015-0088-Response-by-Royal-Orthopaedic-Hospital
Page 2 · response
Published 9 March 2015

Open published response

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

Existing controls and professional responsibilities are considered sufficient to mitigate the small residual risk of medicine diversion.

Verbatim wording from the response

“In summary, the controls around both Controlled Drugs and “non-controlled” drugs have been reviewed. Standard Operating Procedures for Controlled Drugs have been updated and audits conducted by the Chief Pharmacist have shown compliance with the standards required. Controls around “non-controlled” medicines have been reviewed and found to be compliant with or indeed exceed all national guidance. There remains a small risk that these medicines could be diverted as is the case in all hospitals. This is mitigated by the professional responsibilities of all staff regarding the use of medicines. To further mitigate”

Source location

2015-0088-Response-by-Royal-Orthopaedic-Hospital
Page 2 · response
Published 9 March 2015

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.4

  1. 1

    Conduct weekly audits of controlled-drug documentation in theatres.

    Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2015.
  2. 2

    Update standard operating procedures for controlled drugs.

    Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2015.
  3. 3

    Audit organisational governance arrangements for the safe and secure use of controlled drugs and report findings, action plans and progress to governance bodies.

    Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2015.
  4. 4

    Issue medicine-handling responsibility letters and anaesthetic-room standard operating procedures, obtaining staff confirmation of receipt and understanding.

    Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2015.

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

Conduct weekly audits of controlled-drug documentation in theatres.

Verbatim wording from the response

“Since February 2015 a weekly audit of Controlled Drug documentation is carried out by theatres management. Since March 2015 the Chief Pharmacist has carried out unannounced spot audits (normally two per week) on drug storage (all drugs) and documentation in theatres. No concerns regarding diversion or theft of medicines have been identified through this audit cycle and all documentation is correctly completed.”

Source location

2015-0088-Response-by-Royal-Orthopaedic-Hospital
Page 2 · response
Published 9 March 2015

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 standard operating procedures for controlled drugs.

Verbatim wording from the response

“In summary, the controls around both Controlled Drugs and “non-controlled” drugs have been reviewed. Standard Operating Procedures for Controlled Drugs have been updated and audits conducted by the Chief Pharmacist have shown compliance with the standards required. Controls around “non-controlled” medicines have been reviewed and found to be compliant with or indeed exceed all national guidance. There remains a small risk that these medicines could be diverted as is the case in all hospitals. This is mitigated by the professional responsibilities of all staff regarding the use of medicines. To further mitigate”

Source location

2015-0088-Response-by-Royal-Orthopaedic-Hospital
Page 2 · response
Published 9 March 2015

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

Audit organisational governance arrangements for the safe and secure use of controlled drugs and report findings, action plans and progress to governance bodies.

Verbatim wording from the response

“The Chief Pharmacist audited the organisational governance structures for the safe and secure use of Controlled Drugs using the Care Quality Commission’s audit tool in March 2015 and has reported these audit findings, action plans and progress on action plans to the Accountable Officer for Controlled Drugs, the Trust Drugs and Therapeutics Committee and the Trust Clinical Governance Committee.”

Source location

2015-0088-Response-by-Royal-Orthopaedic-Hospital
Page 2 · response
Published 9 March 2015

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

Issue medicine-handling responsibility letters and anaesthetic-room standard operating procedures, obtaining staff confirmation of receipt and understanding.

Verbatim wording from the response

“A letter was issued to all staff in February 2015 clarifying individual staff responsibilities regarding the safe and secure handling of medicines and Standard Operating Procedures (SOPs) were issued to each anaesthetic room. Staff have signed to confirm that they have received, read and understand the documents.”

Source location

2015-0088-Response-by-Royal-Orthopaedic-Hospital
Page 2 · response
Published 9 March 2015

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

Official responses located
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Data last updated 7 September 2026