Unaccounted controlled drugs in care home administration
Care Quality Commission received 3 coroners' reports about this hazard between 10 Mar 2014 and 25 Feb 2020.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 1 of the 2 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“not all CQC Outcomes were considered at the last inspection, purportedly because they did not have anyone available to inspect and review the drugs administration system at the material time”
Original on judiciary.uk ↗ No published response from Care Quality Commission was found for this report.
- 3 years 8 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“Controlled drugs - the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs”
Original on judiciary.uk ↗ Repeated from the earlier report:drugssystemadministration
Care Quality Commission responded, stating 1 specific action.Response (PDF) ↗
“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 [name redacted] 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.”
Stated timescale: between October and December 2018
- 2 years 4 months laterClosely relatedConfidence 0.90 · higha different coroner
“processes had been such that it was not easily identified that drugs were not accounted for e.g. Stock sheets were inaccurate”
Original on judiciary.uk ↗ Repeated from the earlier report:processesdrugs
The most recent report. A response may not be due or published yet.
- All reports to Care Quality Commission
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2014 → 2017Stephen Coulson3 years 8 months after Derrick Rivers · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight problems with the care home's drugs administration system – specifically, failures in reviewing, documenting, and auditing how medicines are handled.
Derrick Rivers · 10 Mar 2014
“not all CQC Outcomes were considered at the last inspection, purportedly because they did not have anyone available to inspect and review the drugs administration system at the material time”
Original on judiciary.uk ↗ Stephen Coulson · 27 Oct 2017
“Controlled drugs - the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs”
Original on judiciary.uk ↗ 2017 → 2020Elaine Renshaw2 years 4 months after Stephen Coulson · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with tracking and accounting for controlled drugs in care settings.
Stephen Coulson · 27 Oct 2017
“the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs”
Original on judiciary.uk ↗ Elaine Renshaw · 25 Feb 2020
“processes had been such that it was not easily identified that drugs were not accounted for e.g. Stock sheets were inaccurate”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“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 [name redacted] 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.”
No published response from Care Quality Commission was found for this report.
Stated action · timescale: between October and December 2018
“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 [name redacted] 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.”
No published response from Care Quality Commission was found for this report. It is the most recent report, so a response may not be due or published yet.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Care Quality Commission at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2014 → 2017 | 0.75 | 0.19 | Closely related · 0.80 | different |
| 2017 → 2020 | 0.80 | 0.17 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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- Non‑compliance with care plans and insufficient incident review5 reports · 2016–2026
- Inadequate repositioning and monitoring of at-risk patients2 reports · 2013–2025
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.