PFD report

Stephen George Coulson · Prevention of Future Deaths report

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Issued 27 Oct 2017•Manchester City

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
5

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
11

Described in responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Report evidence summary

Concerns raised5

  1. Failure of the system for audit of controlled-drug processes
    Part of recurring concern: Unreliable controlled-drug custody, documentation and audit controls
  2. Failure of the system for documentation of controlled drugs
    Part of recurring concern: Unreliable controlled-drug custody, documentation and audit controls
  3. Lack of escalation for admission of patients requiring continued observation or review
    Part of recurring concern: Failure to take timely escalation action when safety thresholds are breached
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.7

  1. Action

    Obtain the revised action plan for the incident, identifying lessons for the Trust.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 28 November 2017.
  2. Action

    Monitor the Trust’s audit of opioid patch monitoring form implementation through quarterly engagement and consider it at the next inspection.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 28 November 2017.
  3. Action

    Review the Trust’s controlled drugs policy and share proposed improvements with the Trust.

    Stated by Care Quality CommissionStated 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.3

  1. Position

    The information currently held provides no evidence that the concerns reflect a systemic issue.

    Stated by Care Quality CommissionDisputes 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

Failure of the system for audit of controlled-drug processes

Wider context from the report

“1) Controlled drugs – the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs ”

Is this part of a recurring concern?

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

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 of the system for documentation of controlled drugs

Wider context from the report

“1) Controlled drugs – the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs ”

Is this part of a recurring concern?

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

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 escalation for admission of patients requiring continued observation or review

Wider context from the report

“2) Observation policy – the lack of escalation of the need to admit patients for observation and review should they fulfil the criteria to require continued observation / review prior to discharge ”

Is this part of a recurring concern?

Yes — Failure to take timely escalation action when safety thresholds are breached.

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 of high-level investigations to identify lessons

Wider context from the report

“3) High Level Investigation – the witness did not accept that any lessons could be learnt from the investigation surrounding the death of the deceased. ”

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

Failure of the system for administration of controlled drugs

Wider context from the report

“1) Controlled drugs – the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs ”

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

Obtain the revised action plan for the incident, identifying lessons for the Trust.

Verbatim wording from the response

“In light of the Regulation 28 report, the Commission obtained the revised action plan regarding this tragic incident, which has been submitted directly to you. This does now identify a number of lessons for the Trust.”

Source location

2017-0307-Response-by-CQC
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

Monitor the Trust’s audit of opioid patch monitoring form implementation through quarterly engagement and consider it at the next inspection.

Verbatim wording from the response

“The policy was updated in November 2017 to include reference to an opioid patch monitoring form. The use of the form should minimise the risk of a similar incident experienced by Mr Coulson being repeated. The trust managers have informed the Commission that they plan to audit implementation of the form. We will monitor this through our quarterly engagement meetings and subsequently consider this at the next inspection, which is likely to take place between October and December 2018.”

Source location

2017-0307-Response-by-CQC
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

Review the Trust’s controlled drugs policy and share proposed improvements with the Trust.

Verbatim wording from the response

“As you are aware, the Trust have a controlled drugs policy in place. The pharmacy team within the Commission has reviewed this policy. The policy is of an acceptable standard, with some suggestions for improvements, such as making it clear who has responsibility for investigating medicines incidents, which occur outside of pharmacy. We will share these with the trust.”

Source location

2017-0307-Response-by-CQC
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

Share suggestions clarifying responsibility for investigating medicines incidents occurring outside pharmacy.

Verbatim wording from the response

“As you are aware, the Trust have a controlled drugs policy in place. The pharmacy team within the Commission has reviewed this policy. The policy is of an acceptable standard, with some suggestions for improvements, such as making it clear who has responsibility for investigating medicines incidents, which occur outside of pharmacy. We will share these with the trust.”

Source location

2017-0307-Response-by-CQC
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

Assess early warning score use and escalation at the next inspection.

Verbatim wording from the response

“That said, we will ensure that the use of the early warning score and escalation is considered at the next inspection. We will also continue to monitor through our quarterly engagement with the Trust.”

Source location

2017-0307-Response-by-CQC
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

Continue monitoring early warning score use and escalation through quarterly engagement with the Trust.

Verbatim wording from the response

“That said, we will ensure that the use of the early warning score and escalation is considered at the next inspection. We will also continue to monitor through our quarterly engagement with the Trust.”

Source location

2017-0307-Response-by-CQC
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

Review the Trust’s controlled drug standard operating procedures through ongoing engagement.

Verbatim wording from the response

“The trust must also have in place a controlled drug Standard Operating Procedures (SOPs). We will review these as part of our ongoing engagement with the trust. For your information, we have recently implemented a system of having a named pharmacist inspector who has responsibility for the Trust and who meets with the head pharmacist. They are aware of this Regulation 28 report and will include this as part of their next meeting.”

Source location

2017-0307-Response-by-CQC
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 information currently held provides no evidence that the concerns reflect a systemic issue.

Verbatim wording from the response

“In addition, in light of the Regulation 28 report, we have also considered whether there is sufficient evidence to take further regulatory action regarding this matter. We have concluded, based on the information we currently hold, that there is no evidence there is a systemic issue. However, please be assured we will continue to monitor the issues you have raised from a regulatory perspective and use the information to inform future regulatory activity at the Trust.”

Source location

2017-0307-Response-by-CQC
Page 3 · 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

No further regulatory action is considered necessary regarding this matter based on the information currently held.

Verbatim wording from the response

“In addition, in light of the Regulation 28 report, we have also considered whether there is sufficient evidence to take further regulatory action regarding this matter. We have concluded, based on the information we currently hold, that there is no evidence there is a systemic issue. However, please be assured we will continue to monitor the issues you have raised from a regulatory perspective and use the information to inform future regulatory activity at the Trust.”

Source location

2017-0307-Response-by-CQC
Page 3 · 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 controlled drugs policy is of an acceptable standard, although improvements to incident-investigation responsibilities have been suggested.

Verbatim wording from the response

“As you are aware, the Trust have a controlled drugs policy in place. The pharmacy team within the Commission has reviewed this policy. The policy is of an acceptable standard, with some suggestions for improvements, such as making it clear who has responsibility for investigating medicines incidents, which occur outside of pharmacy. We will share these with the trust.”

Source location

2017-0307-Response-by-CQC
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.4

  1. 1

    Recommend that local Controlled Drug Accountable Officers remind designated-body officers to participate actively in providing evidence at Coroner’s Inquests.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 28 November 2017.
  2. 2

    Monitor implementation of the revised action plan through quarterly engagement and consider it at the next inspection.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 28 November 2017.
  3. 3

    Continue monitoring the raised issues from a regulatory perspective and use the information to inform future regulatory activity at the Trust.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 28 November 2017.
  4. 4

    Maintain a named pharmacist inspector responsible for the Trust and include the report in the inspector’s next meeting with the head pharmacist.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 28 November 2017.

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

Recommend that local Controlled Drug Accountable Officers remind designated-body officers to participate actively in providing evidence at Coroner’s Inquests.

Verbatim wording from the response

“NHS England will recommend to all Controlled Drug Accountable Officers in each locality to remind the Controlled Drug Accountable Offices of Designated Bodies to ensure they are actively involved in providing evidence at the Coroner’s Inquest.”

Source location

2017-0307-Response-by-NHS-England
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

Monitor implementation of the revised action plan through quarterly engagement and consider it at the next inspection.

Verbatim wording from the response

“As with other significant concerns, we will monitor the action plan through our regular quarterly engagement meetings with the Trust. We will also take into account the action plan and the implementation of these actions at the next inspection.”

Source location

2017-0307-Response-by-CQC
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

Continue monitoring the raised issues from a regulatory perspective and use the information to inform future regulatory activity at the Trust.

Verbatim wording from the response

“In addition, in light of the Regulation 28 report, we have also considered whether there is sufficient evidence to take further regulatory action regarding this matter. We have concluded, based on the information we currently hold, that there is no evidence there is a systemic issue. However, please be assured we will continue to monitor the issues you have raised from a regulatory perspective and use the information to inform future regulatory activity at the Trust.”

Source location

2017-0307-Response-by-CQC
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

Maintain a named pharmacist inspector responsible for the Trust and include the report in the inspector’s next meeting with the head pharmacist.

Verbatim wording from the response

“The trust must also have in place a controlled drug Standard Operating Procedures (SOPs). We will review these as part of our ongoing engagement with the trust. For your information, we have recently implemented a system of having a named pharmacist inspector who has responsibility for the Trust and who meets with the head pharmacist. They are aware of this Regulation 28 report and will include this as part of their next meeting.”

Source location

2017-0307-Response-by-CQC
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

Official responses located
2/3

Data last updated 7 September 2026