PFD report

Mr Thompson Elliott · Prevention of Future Deaths report

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Issued 15 Oct 2025•Sunderland

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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 raised4

  1. Failure to clarify medication changes before continued administration
    Part of recurring concern: Unreliable implementation of medication changesPart of recurring concern: Unreliable medication management in care homesPart of recurring concern: Unsafe medication administrationPart of recurring concern: Unsafe medication management during hospital-to-care-home transitions
  2. Lack of clear procedures for medication management when a discharge letter cannot be located
    Part of recurring concern: Unreliable healthcare patient transfer processesPart of recurring concern: Unreliable medication management in care homesPart of recurring concern: Unsafe medication management during hospital-to-care-home transitions
  3. Failure to escalate medication uncertainty to appropriate clinical advisers
    Part of recurring concern: Unreliable escalation by care staff for required medical attentionPart of recurring concern: Unreliable medication management in care homes
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

    Train staff to escalate hospital-return medication queries, obtain same-day clarification and document communications, actions and handovers.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
  2. Action

    Review hospital discharges monthly for compliance with discharge processes and completion of medication updates and follow-up actions.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
  3. Action

    Reinforce hospital-return, discharge and medication-management policies through mandatory read-and-sign confirmation and refresher training.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.

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 clarify medication changes before continued administration

Wider context from the report

“The evidence has revealed significant concerns with regard to the recording and administration of medication, when patients return to the care home, and a discharge letter cannot be located following a period in hospital. I am concerned that the evidence was that if a patient returned to the care home with new medication prescribed whilst in hospital to replace previously prescribed medication, and the patient’s discharge letter could not be immediately located, there would be uncertainty amongst staff as to the correct procedure to follow in such circumstances. Medication that had been stopped whilst in hospital due to its impact upon the patient’s kidneys continued to be administered on 18th and 19th December 2024, before it could be clarified with either the hospital or GP which was the correct medication. The new medication was not administered on either of those days. The evidence revealed that the new medication was not immediately recorded onto the patient’s electronic medication record (EMAR) and held in a cupboard pending clarification. Despite no clarification and following a 24-hour delay, it was then incorrectly added to the record as new and additional medication - not replacement medication. The medication had been changed to oxycodone due to the impact oramorph was having upon the patient’s kidneys. Due to the administration error in recording oxycodone as new and therefore additional medication, the patient was then given both oramorph and the new oxycodone medication on the morning and afternoon of 20th December 2024 which was 2 days following his discharge. This resulted in an opioid overdose. I am concerned that the evidence was such that it was not possible to determine exactly what efforts, if any, were made by staff to clarify the medication position with the hospital on either 18th, 19th or 20th December 2024 but medication continued to be administered. On 21st December 2024 a team leader was able to speak to the hospital and despite being advised that if there was no discharge letter to take all medications and clarify the position with the GP, a decision was made to only administer the old medication of oramorph and there no attempts to contact the GP. There were no attempts to contact 111 or Recovery at Home for advice. I am concerned that the evidence revealed that there was no policy or guidance document setting out the procedures, which staff must follow in such circumstances, which created confusion and inconsistent decision making resulting in a medication overdose and continued use of a medication that had been stopped in hospital due to the harm it was causing to the patient’s kidneys. The evidence raises a further concern that the procedure still remains unclear despite internal reviews following the death. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

Is this part of a recurring concern?

Yes — Unreliable implementation of medication changes; Unreliable medication management in care homes; Unsafe medication administration; Unsafe medication management during hospital-to-care-home transitions.

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 clear procedures for medication management when a discharge letter cannot be located

Wider context from the report

“The evidence has revealed significant concerns with regard to the recording and administration of medication, when patients return to the care home, and a discharge letter cannot be located following a period in hospital. I am concerned that the evidence was that if a patient returned to the care home with new medication prescribed whilst in hospital to replace previously prescribed medication, and the patient’s discharge letter could not be immediately located, there would be uncertainty amongst staff as to the correct procedure to follow in such circumstances. Medication that had been stopped whilst in hospital due to its impact upon the patient’s kidneys continued to be administered on 18th and 19th December 2024, before it could be clarified with either the hospital or GP which was the correct medication. The new medication was not administered on either of those days. The evidence revealed that the new medication was not immediately recorded onto the patient’s electronic medication record (EMAR) and held in a cupboard pending clarification. Despite no clarification and following a 24-hour delay, it was then incorrectly added to the record as new and additional medication - not replacement medication. The medication had been changed to oxycodone due to the impact oramorph was having upon the patient’s kidneys. Due to the administration error in recording oxycodone as new and therefore additional medication, the patient was then given both oramorph and the new oxycodone medication on the morning and afternoon of 20th December 2024 which was 2 days following his discharge. This resulted in an opioid overdose. I am concerned that the evidence was such that it was not possible to determine exactly what efforts, if any, were made by staff to clarify the medication position with the hospital on either 18th, 19th or 20th December 2024 but medication continued to be administered. On 21st December 2024 a team leader was able to speak to the hospital and despite being advised that if there was no discharge letter to take all medications and clarify the position with the GP, a decision was made to only administer the old medication of oramorph and there no attempts to contact the GP. There were no attempts to contact 111 or Recovery at Home for advice. I am concerned that the evidence revealed that there was no policy or guidance document setting out the procedures, which staff must follow in such circumstances, which created confusion and inconsistent decision making resulting in a medication overdose and continued use of a medication that had been stopped in hospital due to the harm it was causing to the patient’s kidneys. The evidence raises a further concern that the procedure still remains unclear despite internal reviews following the death. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes; Unreliable medication management in care homes; Unsafe medication management during hospital-to-care-home transitions.

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 escalate medication uncertainty to appropriate clinical advisers

Wider context from the report

“The evidence has revealed significant concerns with regard to the recording and administration of medication, when patients return to the care home, and a discharge letter cannot be located following a period in hospital. I am concerned that the evidence was that if a patient returned to the care home with new medication prescribed whilst in hospital to replace previously prescribed medication, and the patient’s discharge letter could not be immediately located, there would be uncertainty amongst staff as to the correct procedure to follow in such circumstances. Medication that had been stopped whilst in hospital due to its impact upon the patient’s kidneys continued to be administered on 18th and 19th December 2024, before it could be clarified with either the hospital or GP which was the correct medication. The new medication was not administered on either of those days. The evidence revealed that the new medication was not immediately recorded onto the patient’s electronic medication record (EMAR) and held in a cupboard pending clarification. Despite no clarification and following a 24-hour delay, it was then incorrectly added to the record as new and additional medication - not replacement medication. The medication had been changed to oxycodone due to the impact oramorph was having upon the patient’s kidneys. Due to the administration error in recording oxycodone as new and therefore additional medication, the patient was then given both oramorph and the new oxycodone medication on the morning and afternoon of 20th December 2024 which was 2 days following his discharge. This resulted in an opioid overdose. I am concerned that the evidence was such that it was not possible to determine exactly what efforts, if any, were made by staff to clarify the medication position with the hospital on either 18th, 19th or 20th December 2024 but medication continued to be administered. On 21st December 2024 a team leader was able to speak to the hospital and despite being advised that if there was no discharge letter to take all medications and clarify the position with the GP, a decision was made to only administer the old medication of oramorph and there no attempts to contact the GP. There were no attempts to contact 111 or Recovery at Home for advice. I am concerned that the evidence revealed that there was no policy or guidance document setting out the procedures, which staff must follow in such circumstances, which created confusion and inconsistent decision making resulting in a medication overdose and continued use of a medication that had been stopped in hospital due to the harm it was causing to the patient’s kidneys. The evidence raises a further concern that the procedure still remains unclear despite internal reviews following the death. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

Is this part of a recurring concern?

Yes — Unreliable escalation by care staff for required medical attention; Unreliable medication management in care homes.

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 accurately record replacement medication on the electronic medication record

Wider context from the report

“The evidence has revealed significant concerns with regard to the recording and administration of medication, when patients return to the care home, and a discharge letter cannot be located following a period in hospital. I am concerned that the evidence was that if a patient returned to the care home with new medication prescribed whilst in hospital to replace previously prescribed medication, and the patient’s discharge letter could not be immediately located, there would be uncertainty amongst staff as to the correct procedure to follow in such circumstances. Medication that had been stopped whilst in hospital due to its impact upon the patient’s kidneys continued to be administered on 18th and 19th December 2024, before it could be clarified with either the hospital or GP which was the correct medication. The new medication was not administered on either of those days. The evidence revealed that the new medication was not immediately recorded onto the patient’s electronic medication record (EMAR) and held in a cupboard pending clarification. Despite no clarification and following a 24-hour delay, it was then incorrectly added to the record as new and additional medication - not replacement medication. The medication had been changed to oxycodone due to the impact oramorph was having upon the patient’s kidneys. Due to the administration error in recording oxycodone as new and therefore additional medication, the patient was then given both oramorph and the new oxycodone medication on the morning and afternoon of 20th December 2024 which was 2 days following his discharge. This resulted in an opioid overdose. I am concerned that the evidence was such that it was not possible to determine exactly what efforts, if any, were made by staff to clarify the medication position with the hospital on either 18th, 19th or 20th December 2024 but medication continued to be administered. On 21st December 2024 a team leader was able to speak to the hospital and despite being advised that if there was no discharge letter to take all medications and clarify the position with the GP, a decision was made to only administer the old medication of oramorph and there no attempts to contact the GP. There were no attempts to contact 111 or Recovery at Home for advice. I am concerned that the evidence revealed that there was no policy or guidance document setting out the procedures, which staff must follow in such circumstances, which created confusion and inconsistent decision making resulting in a medication overdose and continued use of a medication that had been stopped in hospital due to the harm it was causing to the patient’s kidneys. The evidence raises a further concern that the procedure still remains unclear despite internal reviews following the death. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

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

Train staff to escalate hospital-return medication queries, obtain same-day clarification and document communications, actions and handovers.

Verbatim wording from the response

“Discussion and further refresher training with all relevant staff has emphasized the need to ensure home management is informed immediately of any concerns regarding residents returning from hospital and that checks are undertaken with the hospital. The training has reinforced that if the hospital cannot be reached for an answer, colleagues should check with the GP and failing that contact the 111 service.”

Source location

Response from Care UK
Page 1 · response
Published 20 October 2025

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 hospital discharges monthly for compliance with discharge processes and completion of medication updates and follow-up actions.

Verbatim wording from the response

“There is now a monthly review of hospital discharges checking compliance with the relevant processes outlined above; medication is promptly updated and any required follow-up actions completed.”

Source location

Response from Care UK
Page 3 · response
Published 20 October 2025

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

Reinforce hospital-return, discharge and medication-management policies through mandatory read-and-sign confirmation and refresher training.

Verbatim wording from the response

“The care home leadership has reinforced Care UK's 'Admissions and Discharge Policy' (enclosure 2) and the 'How to Guide - Supporting a Resident Returning from Hospital' (enclosure 3) as well as the 'Medications Management Policy' (enclosure 4). These documents provide clear guidance to staff as to what to do in circumstances where a resident arrives and/or returns to the care home from hospital and there is insufficient/absent information regarding their discharge and attendant medications. All staff have completed a mandatory "read and sign" process to confirm that they have read and understood these documents, all of which have been discussed with staff as part of further refresher training sessions undertaken.”

Source location

Response from Care UK
Page 2 · response
Published 20 October 2025

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

Introduce and disseminate a visual flow chart guiding staff through medication checks when residents return from hospital without discharge documentation.

Verbatim wording from the response

“To remind staff, a visual flow chart has been introduced at the care home to provide clear, step-by-step guidance for staff involved in supporting residents returning from hospital where there is no accompanying discharge letter to support changes in medication. A copy of this flow chart, which has been shared and discussed with staff to embed awareness of it, accompanies this letter (enclosure 1). This flowchart is laminated and attached to the medication keys as an immediate prompt to staff. Additionally, there are copies of this flow chart in poster format on the wall of the care home's treatment room and there is a further copy contained within a dedicated discharge file held in the Deputy Manager's office. This dedicated file has been brought in following this case and contains the flow chart prompt and copies of Care UK's relevant up-to-date policies to which I refer below.”

Source location

Response from Care UK
Page 2 · response
Published 20 October 2025

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 working with hospital Trusted Assessors to streamline secure, prompt sharing of discharge information and support safe transitions of care.

Verbatim wording from the response

“The care home has continued to work closely with the Trusted Assessor team at the hospital which discharged Mr Elliott to try to streamline communication/interaction in relation to discharges. The aim is to ensure all documents are securely and promptly shared including via NHS email if possible to support timely and safe transitions of care from hospital to the care home. This work is ongoing but the care home and its hospital partners share a commitment to best practice to achieve these aims. As noted above, the Home Manager has held meetings with the local hospital's Trusted Assessors to discuss the care home's discharge policies to ensure agreement and buy in to the process.”

Source location

Response from Care UK
Page 3 · response
Published 20 October 2025

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

Deliver additional medication education, reflection workbooks, medication-policy confirmation and renewed medication and electronic-record training for staff.

Verbatim wording from the response

“The care home has run extra medication training sessions to raise knowledge of and test understanding of drugs in use at the care home including why they are prescribed, the effects/side effects, brand names and generic names. The refresher training also included how the online British National Formulary should be used. To begin with this additional training focused only on the pain relief medication in Mr Elliott's case but, due to its success, has since focused on other drugs commonly in use at the care home.”

Source location

Response from Care UK
Page 3 · response
Published 20 October 2025

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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

Discuss imminent and new hospital discharges at daily and weekly clinical meetings so required information and follow-up actions are identified.

Verbatim wording from the response

“The Home Manager and/or Deputy will ensure that any imminent or new discharges to the care home are discussed at the daily 10@10 meetings and weekly clinical review meetings to ensure staff are aware of the discharges, the relevant information is obtained and any matters requiring follow-up are actioned. In addition, it is also important to note that there is always a member of the management team available (seven days a week) and so at any time the discharge process is taking place, there are senior staff available to help deal with/advise on any issues arising with the discharge.”

Source location

Response from Care UK
Page 2 · response
Published 20 October 2025

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.1

  1. 1

    Update the hospital travel passport with care-home team-leader contact numbers and reinforce its return with residents after hospital discharge.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.

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 the hospital travel passport with care-home team-leader contact numbers and reinforce its return with residents after hospital discharge.

Verbatim wording from the response

“The care home management team has also re-emphasized (to Care UK colleagues and the hospital Trusted Assessor team) the importance of its hospital travel passport. This document goes with the resident whenever they attend hospital and is requested to be returned with them when they come back. The first page provides a profile of the resident and his/her needs, and full details of their next of kin along with their contact details. The second page is any DNAR/ECHP in place for that resident and the final page is a copy of the EMAR for that resident to ensure the hospital has clear information regarding the relevant medications taken by the resident. The care home has updated the document to ensure that it now contains, in addition to the main care home number, on-call numbers for all of the care home's team leaders to provide hospital staff with a number of potential points of contact.”

Source location

Response from Care UK
Page 3 · response
Published 20 October 2025

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