PFD report

Shahida KHAN · Prevention of Future Deaths report

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Issued 24 Apr 2024•Hampshire, Portsmouth and Southampton

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
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
7

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 raised1

  1. Risk of administration of toxic and fatal quantities of medications to those in the care of staff
    Part of recurring concern: Toxicity risks from excessive or combined medication usePart of recurring concern: Unsafe medication administration
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.5

  1. Action

    Implement an electronic Medication Administration System across the organisation.

    Stated by Voyage CareStated plannedThe respondent said that this action was planned when they made their response on 1 August 2024.
  2. Action

    Review all residents’ care and care plans, including relevant rescue-medication administration protocols.

    Stated by Voyage CareStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
  3. Action

    Renew medication training for all staff at the care home.

    Stated by Voyage CareStated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Further comment and decisions on steps addressing the concerns were constrained pending completion of the Police investigation.

    Stated by Voyage CareUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Risk of administration of toxic and fatal quantities of medications to those in the care of staff

Wider context from the report

“2. The deceased was administered with toxic and fatal quantities of ████████, ████████ and ████████. It cannot be ascertained how this happened. 3. In the absence of an explanation there is a risk of a further recurrence where those in the care of the staff are administered toxic and fatal quantities of medications. ”

Is this part of a recurring concern?

Yes — Toxicity risks from excessive or combined medication use; Unsafe medication administration.

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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

Implement an electronic Medication Administration System across the organisation.

Verbatim wording from the response

“▪ A further related action is the planned implementation of an electronic Medication Administration System across the organisation. This is part of a larger programme of work designed to provide more comprehensive oversight of the delivery of care to residents, including the administration of medication.”

Source location

Response from Voyage Care
Page 2 · response
Published 1 August 2024

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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

Review all residents’ care and care plans, including relevant rescue-medication administration protocols.

Verbatim wording from the response

“As previously stated, we have found no evidence of misadministration by our staff, having completed rigorous medication counts as part of our investigation. We have, however, taken a number of further steps to reduce the risk, insofar as is possible, of a Person We Support being administered toxic and fatal quantities of medications. These include:”

Source location

Response from Voyage Care
Page 2 · response
Published 1 August 2024

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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

Renew medication training for all staff at the care home.

Verbatim wording from the response

“▪ We have reviewed the medication training in the home and are in the process of renewing medication training for all staff at the home.”

Source location

Response from Voyage Care
Page 2 · response
Published 1 August 2024

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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 a further investigation into medication storage, auditing and administration competencies at the care home.

Verbatim wording from the response

“In order to address your specific concerns and those matters which came to light at the inquest on 23 April 2024, specifically regarding medication levels found on postmortem, Voyage conducted a further investigation specifically focused on medication storage, medication audit and medication administering competencies at the care home where Ms Khan resided. This investigated confirmed:”

Source location

Response from Voyage Care
Page 1 · response
Published 1 August 2024

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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

Commission an independent pharmacist to review medication policies, procedures, training content and audits.

Verbatim wording from the response

“▪ We have commissioned an independent pharmacist to review our policies, procedures, training content and audits. Whilst not as a direct result of this sad circumstance, it is relevant to our response as a reflective and responsible provider.”

Source location

Response from Voyage Care
Page 2 · response
Published 1 August 2024

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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

Further comment and decisions on steps addressing the concerns were constrained pending completion of the Police investigation.

Verbatim wording from the response

“is usually given to the People we Support by staff, the investigation by the Police will no doubt have to consider the possible involvement of third parties, for example other visitors to the service. We have confirmed to your office that the matter has been referred to the Police and, in those circumstances, I would respectfully request that this response should not be published until the Police have completed their investigation, to avoid any risk of compromising this. Until the Police complete their investigation it is difficult to comment further, and we will be advised by them as regards next steps including any steps which should be taken to address matters of concern at paragraph 5 of the PFD Report. In liaison with them, we will also take the steps necessary and appropriate, to manage staff, which may include suspension pending the conclusion of investigations.”

Source location

Response from Voyage Care
Page 2 · response
Published 1 August 2024

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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

No evidence was found that Voyage staff misadministered medication, following rigorous medication stock counts and investigation.

Verbatim wording from the response

“As previously stated, we have found no evidence of misadministration by our staff, having completed rigorous medication counts as part of our investigation. We have, however, taken a number of further steps to reduce the risk, insofar as is possible, of a Person We Support being administered toxic and fatal quantities of medications. These include:”

Source location

Response from Voyage Care
Page 2 · response
Published 1 August 2024

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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

Existing medication storage, auditing, competency policies, procedures and staff training were considered robust and subject to audit.

Verbatim wording from the response

“Your concerns touch upon medication storage, medication audit and medication administering competencies. I can confirm that Voyage has established policies and procedures in place to deal with medication storage, medication audit and medication administering competencies, and these were in place at the time of Ms. Khan’s death. Extracts of these have already been provided to you. The policies and procedures are robust and are subject to audit. Staff are trained in all of the areas referred to both on induction and annually.”

Source location

Response from Voyage Care
Page 1 · response
Published 1 August 2024

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.2

  1. 1

    Commission and obtain an independent toxicology review of the postmortem and toxicology evidence.

    Stated by Voyage CareStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
  2. 2

    Refer the unexplained medication overdose to the Police for investigation.

    Stated by Voyage CareStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.

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

  1. 1

    The Police investigation was assigned responsibility for considering third-party involvement and advising on next steps addressing the concerns.

    Stated by Voyage CareRedirects 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

Commission and obtain an independent toxicology review of the postmortem and toxicology evidence.

Verbatim wording from the response

“In addition, having received copies of the postmortem and toxicology reports on 19th April 2024, we instructed an independent Consultant in Chemical Pathology and Forensic Toxicology to review the evidence following our internal investigation. Regrettably, the independent Toxicologist’s investigation and our own medication investigation did not determine the origin of any overdose. In the circumstances we have referred the matter to the Police. Whilst medication”

Source location

Response from Voyage Care
Page 1 · response
Published 1 August 2024

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

Refer the unexplained medication overdose to the Police for investigation.

Verbatim wording from the response

“In addition, having received copies of the postmortem and toxicology reports on 19th April 2024, we instructed an independent Consultant in Chemical Pathology and Forensic Toxicology to review the evidence following our internal investigation. Regrettably, the independent Toxicologist’s investigation and our own medication investigation did not determine the origin of any overdose. In the circumstances we have referred the matter to the Police. Whilst medication”

Source location

Response from Voyage Care
Page 1 · response
Published 1 August 2024

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 Police investigation was assigned responsibility for considering third-party involvement and advising on next steps addressing the concerns.

Verbatim wording from the response

“is usually given to the People we Support by staff, the investigation by the Police will no doubt have to consider the possible involvement of third parties, for example other visitors to the service. We have confirmed to your office that the matter has been referred to the Police and, in those circumstances, I would respectfully request that this response should not be published until the Police have completed their investigation, to avoid any risk of compromising this. Until the Police complete their investigation it is difficult to comment further, and we will be advised by them as regards next steps including any steps which should be taken to address matters of concern at paragraph 5 of the PFD Report. In liaison with them, we will also take the steps necessary and appropriate, to manage staff, which may include suspension pending the conclusion of investigations.”

Source location

Response from Voyage Care
Page 2 · response
Published 1 August 2024

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