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recurance

Kumbulani Mtombeni

16 Aug 2021 · Coroner Lydia Brown · West London

The coroner's concerns

  1. 1. unauthorised possession of methadone by staff

    “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 [name redacted] 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 [name redacted] possession? (2) Were any audits performed that demonstrated missing medication and if so, what actions were taken? (3) What actions”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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