APEX Helping people remain in control of their lives David Gregory OBE QPM Coroner's Officer, Portsmouth Office Hampshire, Portsmouth, and Southampton Coroners Service The Coroner's Court 1 Guildhall Square Portsmouth P01 2GJ Regulation 28 report to prevent future deaths Tracy Marie Brown Inquest O6 December 2022 14 Bartram Road Tatton Southampton Hampshire SO409JG Following on from the recommendations from the coroner's report there were recommendations with reference to the medication and how it was stored. When TB moved into Bresler house in March 2021 we were commissioned to provide a package of care for TB. The senior carer went and completed the initial assessment which included setting out a care plan and completing the risk assessments.
• 30mins (AM before 12pm) 7 days a week to help with prompting personal care, supporting with preparing food and drink, supporting to prompt medication, to help with social isolation.
• 4:30pm 15mins 7 days a week to help with prompting personal care, supporting with preparing meal and drink, supporting to prompt medication, to help with social isolation.
• 08:30pm 15mins 7 days a week to help with prompting personal care, supporting with preparing food and drink, supporting to prompt medication, to help with social isolation.
• 1hr per week additionally to support with maintaining home conditions, laundry and changing the bedding. The assessments were completed, and the care plan written up. The sheltered housing scheme manager was happy to support in prompting Tracey to take her medication the medication was in a nomad which was delivered to the Bresler house office, and the staff would keep it until TB was ready for it. This would cause us problems as when we needed to get a new nomad the staff weren't always available, and the office locked, so if there was just one lot of medication left, we would go to the office to collect new nomad and place in the locked tin. The tin was small and only had room for one nomad at a time.

Apex Prime Care Ltd Registered Office Windsor House, Bayshill Road, Cheltenham GLS0 3AT Registered Number 4296566

On some occasions TB would be out when we were commissioned to go in to carry out the care so we would inform Bresler staff, and they would then help TB to take her medication. Since the passing of TB Apex Prime Care have learnt valuable lessons with reference to medication, we quickly reassessed every service user that has medication in a locked box to store medication. There now must be room to place all medication in the locked box with no other medication stored in the property. Some service users have had to purchase 2 locked boxes to fit all the medication in or a safe. If the delivery is weekly only, when we do the assessment, we reiterate to the service user or their families not to buy over the counter medication as we are unable to monitor this closely and are unaware of what the service user is taking. There is a task on the care plan of how medication is to be given and where it is stored but, on this occasion, it wasn't which I should have picked up when I audited the care plan before going into the service user's property. I have learnt a valuable lesson and I have filtered this down to all my office staff and no care plans go out without this task in place. Apex Prime Care has also changed their medication policy to reflect medication and locked boxes {I have included the new updated policy and highlighted in yellow the changes to the policy).