PFD report

Joan Wright · Prevention of Future Deaths report

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Issued 28 Dec 2018•Manchester South

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: 9
Recipients: 1
Responses found: 1
Stated actions: 6

Recipients and published responses

Department of Health and Social CareResponse found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 18th September 2017 I commenced an investigation into the death of Joan Wright. The inquest concluded on the 12th December 2018 and the conclusion was one of Natural Causes

The medical cause of death was 1a) Acute myocardial insufficiency;
1b) Coronary artery atheroma

Coroner’s concerns

1. The inquest heard that Oramorph had different classifications depending on the strength prescribed. This impacts the storage/handling arrangements. The inquest heard that opioids can have a significant impact at whatever strength they are prescribed if given in excess;
2. Evidence was given that because of the abolition of PCT and replacement with CCG’s there was no designation of the CCG’s as designated bodies with statutory responsibility in relation to drugs. This was an oversight but has not been corrected;
3. Following the maladministration of medication to Mrs Wright, the inquest heard that the matter was reported to GMP .The CDLO investigated but did not liaise with the local police unit or discuss the safeguarding implications;
4. GMP’s call handler did not recognise the potential safeguarding risks of the maladministration of opioids to a vulnerable member of the community and referred the report to the local division. The local division assessor (LRO) failed to recognise the safeguarding risks and filed the report as theft. GMP have changed their policies significantly since the matter was referred to them after Mrs Wright’s death. However it was unclear about whether or not the issue had been addressed by Forces nationally. The inquest was told that the CDLO role had been brought in after the Shipman inquiry to ensure safeguarding risks were identified in relation to maladministration of drugs;
5. The home in question has been rated as inadequate by CQC and was under regular monitoring via an action plan. It was also being visited regularly by the Local Authority Quality Support Team every 10 days or so. One of the issues previously identified was poor management/documentation of medication. Notwithstanding that, access and unauthorised repeated administration of Oramorph took place;
6. The CQC gave evidence that the legislation requires regular checks by care homes in relation to medication but there is no statutory definition of what regular means. As a result in some it is monthly in others weekly.

Concerns and recipient responses

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

Concerns raised9

Poor management and documentation of medication
Part of recurring concern: Unreliable medication management in care homes
Failure to prevent unauthorised access and repeated administration of Oramorph
Part of recurring concern: Unreliable medication management in care homes Part of recurring concern: Unsafe medication administration
Failure of GMP call handlers to recognise safeguarding risks in opioid maladministration reports
Part of recurring concern: Unreliable safeguarding response to medication maladministration

Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response 3

Action
Deploy additional clinical pharmacists in primary care and care homes.
Stated by Department of Health and Social CareStated in progress
Action
Implement the Controlled Drugs Regulations establishing tighter controls and mandatory governance arrangements for prescribing, records, custody, monitoring and accountable officers.
Stated by Department of Health and Social CareStated completed
Action
Accelerate rollout of electronic prescribing for controlled drugs and medicines administration.
Stated by Department of Health and Social CareStated in progress

Respondent positions 3

Position
Existing controlled-drug governance measures are considered sufficient to detect and minimise inappropriate use, although they cannot prevent every incident.
Stated by Department of Health and Social CareExisting arrangements considered sufficient

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 3

1
Undertake and publish the statutory post-implementation review of the 2013 Controlled Drugs Regulations before 31 March 2020.
Stated by Department of Health and Social CareStated planned
2
Develop a programme of work to improve medicines safety in response to the World Health Organization medicines-safety challenge.
Stated by Department of Health and Social CareStated in progress
3
Introduce monitoring of the highest-risk prescribing practices linked to hospital admissions.
Stated by Department of Health and Social CareStated completed

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised9

Poor management and documentation of medication

Failure to prevent unauthorised access and repeated administration of Oramorph

Failure of GMP call handlers to recognise safeguarding risks in opioid maladministration reports

Significant impact from excess administration of opioids at any prescribed strength

Failure of local division assessors to recognise safeguarding risks in opioid maladministration reports

Failure to maintain consistent classification-based storage and handling arrangements for Oramorph

Lack of a statutory definition of the required frequency of medication checks by care homes

Failure of the CDLO to liaise with the local police unit and discuss safeguarding implications

Lack of designation of CCGs as bodies with statutory responsibility for drugs

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.3

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

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

Actions described in response 3

Respondent positions 3

Recipient-stated actions 3