Dear Coroner Lydia Brown

Inquest into the death of Kumbulani Mtombeni (died 25/01/2021)

I write further to the report issued under Regulation 28 of the Coroners (Investigations) Regulations 2013 and to outline the action that has been taken by Care Outlook since the inquest into the death of Kumbulani Mtombeni

Background:

1. Grassy Meadow is an Extracare Independent Living Scheme. Care Outlook took over the care services on 1/4/2019.
2. was receiving 4 calls daily to support with personal care, meal preparation and medication.
3. had COPD, suffered with depression, a substance mis-user, ex cocaine user and on methadone.
4. Following hospital admission on 6/7/19, Care Outlook supported Hospital discharge on 16/7/2019 by agreeing to administer Methadone, a controlled drug.
5. Mr. Mtombeni was a carer regularly going into home prior to his hospital admission and continued on discharge from hospital.
6. Mr Mtombeni was not someone that presented as using drugs/methadone, there was no indication he was taking that medication and cannot explain how methadone was in his possession.
7. had a daily dose of methadone administered. His condition would have deteriorated without the medication. There was no evidence to suggest the medication was not being administered.
8. No concerns were raised by other care workers or supervisors attending of a deterioration which would suggest medication had not been administered. Care Outlook 2-10 Laurel Grove, Sydenham, London SE26 4JY info@careoutlook.co.uk

Care Outlook Ltd. Reg. address: 2-10 Laurel Grove, London, SE26 4JY. Corporation. No. 5302971

9. Medication is stored in the SU’s flats. Methadone being a controlled drug was stored in a locked safe in flat and the key locked in the office. Care workers signed for the keys when removed and returned to the office.
10. MAR charts were audited and recorded that medication administration was compliant
11. Senior care staff carried out daily audits of medication administered for all SU to ensure medication compliance. No concerns were raised.
12. Medication was delivered by the pharmacy to the office and signed for
13. methadone was delivered by the pharmacy on two separate days of the week. First delivery and a second delivery of This was agreed to reduce the amount of methadone on site at Grassy Meadow.,.
14. Care Outlook was informed by the daughter that sadly passed away on 25/1/2020.
15. The unused methadone was collected by the pharmacy on 25/2/2020. Daya pharmacy confirmed (one week) of unused methadone was collected and signed for..

Issues Identified:

In reviewing this case we have identified a deficiency in so far that the signature on the MAR charts were not verified by the second carer / senior. The auditor of the medication was unaware that, unlike normal medication, controlled drugs require a witness Mr Mtombeni appears to have obtained the drugs by deception While speculative Mr Mtombeni may have been deceptive in his administration. If so, a witness countersigning the MAR to verify the SU had been seen to take the medication as prescribed would have made it more arduous passed away 25 January 2020 (not the summer as stated in the report).

Remedial Action:

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.

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.

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