PFD report

Kumbulani MTOMBENI · Prevention of Future Deaths report

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Issued 16 Aug 2021•West London

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 raised2

  1. Failure to control staff access to residents' prescribed medication
    Part of recurring concern: Failure to secure and control medicationPart of recurring concern: Unsafe medication administration
  2. Failure to audit for missing 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.2

  1. Action

    Develop a robust action plan covering controlled-drug training and ongoing medication monitoring for auditors and managers.

    Stated by Care OutlookStated completedThe respondent said that this action was complete when they made their response on 19 August 2021.
  2. Action

    Introduce a digital care-planning and monitoring system providing real-time medication records and improved detection of errors or false reporting.

    Stated by Care OutlookStated completedThe respondent said that this action was complete when they made their response on 19 August 2021.

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 control staff access to residents' prescribed medication

Wider context from the report

“In the deceased's possession was a ████████ of methadone in the name of ████████. Evidence was given at inquest that Mr ████████ was one of your residents until he died last summer. Mr Mtombeni was a member of your staff and at times had worked as a senior carer and had responsibility for and access to the residents prescribed medications. (1) Can you explain how the methadone was in Mr Mtombeni's possession? (2) Were any audits performed that demonstrated missing medication and if so, what actions were taken? (3) What actions will now be taken in the light of the findings at inquest? ”

Is this part of a recurring concern?

Yes — Failure to secure and control medication; Unsafe medication administration.

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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 for missing medication

Wider context from the report

“In the deceased's possession was a ████████ of methadone in the name of ████████. Evidence was given at inquest that Mr ████████ was one of your residents until he died last summer. Mr Mtombeni was a member of your staff and at times had worked as a senior carer and had responsibility for and access to the residents prescribed medications. (1) Can you explain how the methadone was in Mr Mtombeni's possession? (2) Were any audits performed that demonstrated missing medication and if so, what actions were taken? (3) What actions will now be taken in the light of the findings at inquest? ”

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

Develop a robust action plan covering controlled-drug training and ongoing medication monitoring for auditors and managers.

Verbatim wording from the response

“Due to our findings a robust action plan was developed based on lessons learnt to ensure all auditors and managers understood their obligations under CQC regulations in respect of administration of controlled drugs including training and ongoing monitoring.”

Source location

2021-0272-Response-from-Care-Outlook_Published
Page 2 · response
Published 19 August 2021

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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

Introduce a digital care-planning and monitoring system providing real-time medication records and improved detection of errors or false reporting.

Verbatim wording from the response

“Care Outlook has introduced a digital care planning and monitoring system (Access Care Planning) which includes live medication records to be accessed in real time by all stakeholders (subject to customer consent). This increases transparency and opportunities for errors or false reporting to be identified.”

Source location

2021-0272-Response-from-Care-Outlook_Published
Page 2 · response
Published 19 August 2021

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

    Review the support available to staff experiencing mental-health issues.

    Stated by Care OutlookStatus unclearThe respondent did not make the status of this action clear when they made their response on 19 August 2021.

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 support available to staff experiencing mental-health issues.

Verbatim wording from the response

“A Full review of the support available to our staff who may be experiencing Mental Health issues”

Source location

2021-0272-Response-from-Care-Outlook_Published
Page 2 · response
Published 19 August 2021

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