PFD report

Ronald Maurice Brewer · Prevention of Future Deaths report

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Issued 19 Oct 2017•Gloucestershire

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

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 raised3

  1. Deficiencies in the dispensation of palliative medications
  2. Deficiencies in the administration of medications
    Part of recurring concern: Unsafe medication administration
  3. Failure to document palliative medications
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.9

  1. Action

    Appoint a palliative-care Deputy Manager to support end-of-life training and practice, supervise implementation, and develop local palliative-care team involvement.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 28 November 2017.
  2. Action

    Provide clinical supervision on the home’s medication-transcription policy following the identified transcription error.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 28 November 2017.
  3. Action

    Assess staff competencies and practices in medicine management and record keeping.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 28 November 2017.

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

  1. Position

    The highest-end prescribed Midazolam dose was considered appropriate, based on the resident’s individual factors and agitation.

    Stated by Barchester Healthcare LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Deficiencies in the dispensation of palliative medications

Wider context from the report

“1. The administration of medications, including in particular the documentation of and dispensation of palliative medications. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Deficiencies in the administration of medications

Wider context from the report

“1. The administration of medications, including in particular the documentation of and dispensation of palliative medications. ”

Is this part of a recurring concern?

Yes — 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 document palliative medications

Wider context from the report

“1. The administration of medications, including in particular the documentation of and dispensation of palliative medications. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Appoint a palliative-care Deputy Manager to support end-of-life training and practice, supervise implementation, and develop local palliative-care team involvement.

Verbatim wording from the response

“a. A Deputy Manager has been appointed at Badgeworth Court with a background in palliative care and she has been given the responsibility to support training and practice in end of life care in the home. Also to continue”

Source location

2017-0306-Response-by-Barchester-Healthcare-Ltd
Page 1 · response
Published 28 November 2017

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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

Provide clinical supervision on the home’s medication-transcription policy following the identified transcription error.

Verbatim wording from the response

“h. We considered a recording error made when Mr Brewer’s discharge notes were transcribed on admission. Two staff members failed to correctly transcribe Rivaroxaban from the hospital chart to the care home MAR chart. Following investigation the staff members conceded that, during transcription they had failed to consult the discharge summary and had solely referred to the hospital MAR. Clinical supervision was given to the two staff members on the relevant home policy regarding transcription. Both staff members no longer work in the home.”

Source location

2017-0306-Response-by-Barchester-Healthcare-Ltd
Page 3 · response
Published 28 November 2017

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

Assess staff competencies and practices in medicine management and record keeping.

Verbatim wording from the response

“b. The staff at Badgeworth Court have undertaken an assessment of their competencies and practices in relation to management of medicines and they have attended further training on this topic and in relation to record keeping.”

Source location

2017-0306-Response-by-Barchester-Healthcare-Ltd
Page 2 · response
Published 28 November 2017

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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

Update central medicine-management and end-of-life policies to reflect good practice.

Verbatim wording from the response

“j. Policies and procedures have been updated centrally to reflect good practice in medicine management and End of life care.”

Source location

2017-0306-Response-by-Barchester-Healthcare-Ltd
Page 4 · response
Published 28 November 2017

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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

Revisit end-of-life and medication policies with staff and reinforce multidisciplinary working.

Verbatim wording from the response

“e. The end of life and management of medication policies have been re-visited with staff and we have reiterated the importance of multi-professional working in end of life care.”

Source location

2017-0306-Response-by-Barchester-Healthcare-Ltd
Page 2 · response
Published 28 November 2017

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

Use the Zomorph recording error as a learning point in staff supervision, training, and assessment.

Verbatim wording from the response

“i. Whilst investigating the drug administration notes and checking remaining stocks of Zomorph it was noted that a recording error had taken place during the first administration of the drug at Badgeworth Court. The dose had been recorded on the hospital MAR chart instead of the newly created home MAR chart. The error created two distinct risks;”

Source location

2017-0306-Response-by-Barchester-Healthcare-Ltd
Page 3 · response
Published 28 November 2017

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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

Update end-of-life and medication policies with guidance on individualised dosing decisions for prescribed dosage ranges, including analgesia and controlled medicines.

Verbatim wording from the response

“g. In our review it was noted that during Mr Brewer’s end of life care, a decision was made to administer Midazolam at a dose at the highest end of the prescribed dose range. Our finding was that the decision was appropriate and was made by an experienced nurse having considering the individual factors specific to Mr Brewer including his height, weight and level of agitation. Nevertheless, it was identified that more could be done to support”

Source location

2017-0306-Response-by-Barchester-Healthcare-Ltd
Page 2 · response
Published 28 November 2017

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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

Deliver three months of training covering end-of-life planning, anticipatory care, communication, medication decision-making, and medication management.

Verbatim wording from the response

“d. The General Manager at Badgeworth has arranged for ongoing training over the next 3 months, the training is to cover;”

Source location

2017-0306-Response-by-Barchester-Healthcare-Ltd
Page 2 · response
Published 28 November 2017

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

Provide further staff training on medicine management and record keeping.

Verbatim wording from the response

“b. The staff at Badgeworth Court have undertaken an assessment of their competencies and practices in relation to management of medicines and they have attended further training on this topic and in relation to record keeping.”

Source location

2017-0306-Response-by-Barchester-Healthcare-Ltd
Page 2 · response
Published 28 November 2017

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

The highest-end prescribed Midazolam dose was considered appropriate, based on the resident’s individual factors and agitation.

Verbatim wording from the response

“g. In our review it was noted that during Mr Brewer’s end of life care, a decision was made to administer Midazolam at a dose at the highest end of the prescribed dose range. Our finding was that the decision was appropriate and was made by an experienced nurse having considering the individual factors specific to Mr Brewer including his height, weight and level of agitation. Nevertheless, it was identified that more could be done to support”

Source location

2017-0306-Response-by-Barchester-Healthcare-Ltd
Page 2 · response
Published 28 November 2017

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.3

  1. 1

    Emphasize anticipatory end-of-life care during weekly GP resident reviews, including multidisciplinary palliative-care advice.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 28 November 2017.
  2. 2

    Develop an anonymised case study from this case for staff induction and workshop learning resources.

    Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 28 November 2017.
  3. 3

    Provide end-of-life e-learning and require registered nurses to complete it.

    Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 28 November 2017.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The medical practitioner, not the care home, is responsible for deciding whether to prescribe end-of-life medication.

    Stated by Barchester Healthcare LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Emphasize anticipatory end-of-life care during weekly GP resident reviews, including multidisciplinary palliative-care advice.

Verbatim wording from the response

“f. Greater emphasis has been placed on anticipatory end of life care during weekly local GP visits. The home conducts a round of all residents where the GP and staff can address relevant issues. Although the decision to prescribe end of life medication is the responsibility of the medical practitioner, it is best practice to discuss such care using a multi-disciplinary team approach involving the local palliative team for advice and guidance.”

Source location

2017-0306-Response-by-Barchester-Healthcare-Ltd
Page 2 · response
Published 28 November 2017

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

Develop an anonymised case study from this case for staff induction and workshop learning resources.

Verbatim wording from the response

“k. The facts of this case, anonymised, will now form the basis of a case study which forms part of a learning resource for staff during induction and workshops.”

Source location

2017-0306-Response-by-Barchester-Healthcare-Ltd
Page 4 · response
Published 28 November 2017

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

Provide end-of-life e-learning and require registered nurses to complete it.

Verbatim wording from the response

“c. Training has been made available through the Boots pharmacy e-learning modules in end of life care. Our registered nurse staff have been required to complete this training.”

Source location

2017-0306-Response-by-Barchester-Healthcare-Ltd
Page 2 · response
Published 28 November 2017

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

The medical practitioner, not the care home, is responsible for deciding whether to prescribe end-of-life medication.

Verbatim wording from the response

“f. Greater emphasis has been placed on anticipatory end of life care during weekly local GP visits. The home conducts a round of all residents where the GP and staff can address relevant issues. Although the decision to prescribe end of life medication is the responsibility of the medical practitioner, it is best practice to discuss such care using a multi-disciplinary team approach involving the local palliative team for advice and guidance.”

Source location

2017-0306-Response-by-Barchester-Healthcare-Ltd
Page 2 · response
Published 28 November 2017

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