Geoffrey Banks

Your reference 
Our reference 
Date 

24 January 2021 

Margaret J Jones 
Assistant Coroner 
Stoke-on-Trent & N Staffs Coroner’s Court 
HM Coroner’s Court & Chamber 
Stoke Town Hall 
Kingsway 
Stoke-on-Trent 
ST4 1HH 

24th January 2021 

Dear Mrs Jones, 

Adult Social Care, Health Integration and 
Wellbeing  
Civic Centre, Glebe Street 
Stoke-on-Trent 
ST4 4HH 

.  
Thank  you  for  sending  me  a  copy  of  your  Section  28  Report  dated  27th  November  2020, 
following  an  inquest  into  the  death  of  Geoffrey  Peter  Banks  (GB)  which  concluded  on  24th 
November 2020. The conclusion of the inquest was that the deceased died from a heart attack 
and that a self-administered overdose of medication 8 days earlier contributed to his death. It 
was not possible to determine whether the overdose had been accidental or deliberate 

The first matter of concern was stated as: 

The deceased resided at Oak Priory and was the tenant of a privately rented flat in a 
scheme from a housing provider. He was on a care package provided by Comfort Call 
under a contract from Stoke on Trent Council. He received visits four times per day 
principally  to  administer  medication.  The  medicine  was  kept  in  a  locked  kitchen 
cupboard  in  his  flat.  He  had  been  identified  as  not  being  able  to  manage  his  own 
medication. The tenant was easily able to pull open the cupboard door and the barrel 
of the lock fell out. He overdosed on medication. There appears to be no system of 
safe storage in place where a resident has been identified as needing supervision with 
medication. 

The  Coroner’s  report  was  received  by  me  on  4th  December  2020.   Since  that  date  I  have 
undertaken the following actions: 

•  The report and concerns were shared and discussed with both Comfort Call, the Care 
Provider, and Your Housing Group, the landlord of the Extra Care Housing Scheme, 
at the Council’s monthly contract management meeting on 22nd December 2020.  

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Telephone: 01782 234 234      stoke.gov.uk     

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  We  agreed  that  GB  resided  at  Oak  Priory,  an  Extra  Care  Housing  Scheme 
commissioned by Stoke on Trent Council, and received four calls a day from Comfort 
Call, the Care Provider on site, principally to administer medication.  

• 

It was confirmed that the medication cupboards conformed with the specification set 
out in the contract that the City Council has with the provider 

•  The  medication  was kept  in  a  locked  cupboard  in  the  kitchen  which  GB  had forced 
open. Whilst it had been identified that GB was not able to manage his own medication 
and might forget to take his medication, there were no indicators that GB was at risk 
of deliberate or accidental overdose. 

•  Co-codamol  is  not  a  controlled  drug  and therefore  did  not require additional  secure 

measures. 

At that meeting on 22nd December 2020, we discussed and agreed the following actions: 

Action 

Who is responsible 

T 
Target Completion Date 

Specification of lockable cupboards in 
contracts of all Extra Care Housing 
Schemes to be reviewed    
All lockable cupboards in PFI Extra 
Care Housing Schemes to be 
inspected to check on general state of 
repair – If the inspection identifies any 
faults then these should be urgently 
rectified/repaired 
Reviews to be undertaken of care 
plans for all tenants in receipt of care 
who are unable to manage their own 
medication. 

•  Review risk of 

deliberate/accidental overdose 

•  Consider installation of more 

secure storage where required 
Communication to be sent to all home 
care and extra care providers 
requesting that medication storage is 
reviewed for those customers that are 
unable to manage their own 
medication. 

Stoke on Trent 
City Council 

28/02/21 

Your Housing 
Group 

28/02/21 

Stoke on Trent 
City Council/ 
Comfort Call 

Your Housing 
Group 

28/02/201 

28/02/201 

Stoke on Trent 
City Council 

31/01/2021 

In summary this will ensure that, if a resident is identified as needing support with medication 
for any reason, a full review will be undertaken to decide whether or not the existing storage 
arrangements for medication are satisfactory or need enhancing.  I believe that this satisfies 
your first concern as set out in the Section 28 notification. 

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 The second matter of concern was stated as: 

The apparent investigation into the incident was perfunctory and carried out by an 
untrained member of staff. 

We  have  conducted  a  review  into  our  records  and  we  are  clear  that,  in  relation  to  any 
assessment  and  review  undertaken  by  the  Stoke-on-Trent  City  Council  these  were  all 
undertaken  by  a  trained  and  qualified  social  worker.  The  notes  on  the  case  file  and  the 
assessment and support plan for GB was completed by a qualified social worker and while no 
specific  risk  assessment  in  relation  to  medication  had  been  undertaken  a  range  of 
assessments were in place and had been done by a suitably qualified member of staff. Any 
internal review of a death that raised any concerns would be undertaken or overseen by the 
Principal Social Worker or Assistant Director (Adult Social Care). 

In summary, I am confident that all appropriate assessments and reviews that were done by 
the City Council were undertaken by a qualified social worker.  I believe that this should satisfy 
your second concern as set out in the Section 28 notification. 

I hope that I have been able to reassure you that we have carefully reviewed our processes 
and contracts and are confident that the measures we have put in place will reduce the risk of 
a similar situation happening in the future. 

Please let me know if I can help you any further. 

Yours sincerely 

Director of Adult Social Care, Health Integration and Wellbeing  
Email 
Contact number 

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Cardinal House 
Abbeyfield Court 
Abbeyfield Road 
Nottingham 
NG7 2SZ 

T: 

Margaret Jones 
Assistant Coroner 
HM Coroner’s Court & Chamber 
Stoke Town Hall 
Kingsway 
Stoke-on-Trent 
ST4 1HH 

Via email to: 

25 January 2021 

Dear Madam 

Regulation Report to Prevent Future Deaths – Geoffrey BANKS 

Thank for your reg.28 report of 27th November 2020 following the conclusion of the inquest into the 
death of the aforementioned Mr Banks. 

Firstly, I regret I must inform you that despite repeated attempts to engage with Stoke on Trent City 
Council in preparation of this response, I have to date received no substantive contact at all from 
 (Senior Commissioning Officer) is that the matter was 
them. My understanding from 
passed to the Council’s Legal and Quality Assurance Departments for consideration, but I have not 
been given any named contacts and have had no correspondence or acknowledgement from 
either department. Owing to the particular circumstances of the case, this is most regrettable, as 
will become apparent in what follows. 

Before I turn to the concerns raised in your report, I should inform you that following a recent re-
tender by Stoke City Council, Comfort Call will no longer be providing the care services at Oak 
Priory Extra Care scheme from April 2020 and it will therefore be for the Council, the housing 
provider and the new incumbent to consider what changes may be needed to implemented at the 
site once we have left. 

Although we will no longer be providing care at Oak Priory after March, we do intend to take Mr 
Banks’s sad death as an opportunity to reflect on practice across our Extra Care services in other 
locations across England. 

Storage of medication 

You express your concern that Mr Banks, who had been assessed as not being able to safely 
manage his own medicines, was able, with some ease, to break into the kitchen cabinet used to 
store his medicines and to take an overdose of Co-codamol, which contributed to his death. 

City & County Healthcare Group Ltd Registered Office: Caparo House, 101-103 Baker Street, London, W1U 6LN. 
Registered in England and Wales. Registration Number 6991398 

 
 
 
 
 
 
 
 
 
 
 Addressing the situation that allowed Mr Banks access to his medicines is more complicated than 
might appear at first glance, owing to the particular context of an Extra Care Scheme (“ECS”) like 
Oak Priory. An ECS is fundamentally an independent living model and thus quite distinct from 
residential or nursing care in a number of ways: 

-  Those living in the scheme are usually private tenants and their flats are separate private 

homes within the building; 

-  Primary control of the fabric of the building, including fixtures and fittings within each 
tenant’s home, rests with the tenant and the housing provider, not the care provider; 

-  Whilst the care provider typically has a 24-hour presence on site, it does not necessarily 

provide a service to every tenant at the location (although it may be required to be available 
for emergency response); 

-  The service provided is, from a regulatory perspective, essentially the same as home care 

delivered to people living in their own homes in the community.  

Whilst an ECS like Oak Priory looks superficially like a residential home, it is in fact nothing of the 
kind for the purposes of managing and delivering care. For example, in a residential or nursing 
home, medication would typically be stored and dispensed centrally by staff, and centralised 
records maintained. Such an arrangement at Oak Priory would clearly have prevented Mr Banks 
from accessing his medicines unsupervised, but it could not be done lawfully in an ECS under 
Comfort Call’s CQC registration because his medicines belonged to him and it was therefore 
required that they remain in his home (i.e. his flat). 

This does of course raise the question of whether the problem was in fact that Mr Banks was not in 
the correct care setting for his needs. It is certainly our experience that some people are placed in 
ECS inappropriately where their care needs are such that they really require a higher level of 
supervision than such a setting can realistically provide. There are also often challenges where 
people with e.g. dementia are placed in ECS presenting either a risk to themselves (from e.g. 
wandering out of the scheme) or to others (by e.g. entering others’ flats uninvited and occasionally 
presenting challenging behavior). 

In Mr Banks’s case, however, there were no obvious signs that the ECS was an inappropriate care 
setting. He had no previous history of overdose or any other form of self-harm, nor of trying to 
access his medicines and as such, there was no indication that he was at risk in that way. Had 
there been any indication that he was a danger to himself or others, we would certainly have raised 
this as a safeguarding matter, which may well have led to the Council considering alternative 
accommodation for him. 

In view of the fact that his actions could not reasonably have been foreseen and that Comfort Call 
could not have taken his medicines out of his flat, the only conceivable remaining measure in the 
context of the ECS that might have prevented him taking the overdose would have been a 
medicines cabinet in his flat sufficiently secure that he could not have broken into it. The use of 
such a secure cabinet would raise further issues around mental capacity, consent, restrictive 
practice etc., but these could have been addressed with reference to the usual ‘best interests’ 
principles (within the meaning of the Mental Capacity Act 2005). 

Unfortunately, as noted above, Comfort Call has no remit or capability to mandate, purchase or 
install fittings and fixtures in flats at Oak Priory or any other ECS. We are entirely dependent on the 
housing provider and commissioning authority in that regard. We could, however, at least bring our 
influence to bear in that regard, by: 

1.  Raising a safeguarding concern where there is a perceived risk that an individual may be at 

risk from gaining access to their own medicines; and 

2.  Ensuring that as a matter of course, we discuss and agree protocols for the secure storage of 

medicines with the housing provider at each EC. 

 
 Point 1 is already incorporated into our safeguarding procedures. In Mr Banks’s case, it would not 
have made a difference, however, because there was no obvious reason to consider him at 
particular risk from self-harm, either intentionally or as a result of dementia/confusion. 

Point 2, however, can absolutely be incorporated into our standard procedures, which include 
setting up written protocols with partner housing providers addressing the whole range of joint 
working arrangements in each ECS. 

Our plan for organisational learning is, therefore, to review our standard ECS protocols template to 
consider the question of secure medicines storage in each flat and to require all our ECS 
managers to undertake a review at their schemes to consider whether this issue should be raised 
with the housing provider. We will complete this by the end of March 2021. 

Incident investigations 

You also raise a concern that the member of staff that initially investigated following Mr Banks’s 
admission to hospital had not received formal investigation training and that the written report was 
“perfunctory”. 

In mitigation, we would point out that at the time of the investigation, Mr Banks was unwell in 
hospital, but was not expected to die. We do not doubt that had he died sooner, the investigation 
would have been taken over by the Registered Manager rather than being left to a Team Leader 
as in fact happened. 

However, we do accept that the investigation was not as thorough or as detailed as we would have 
liked. The inquest heard that neither the Team Leader nor the Registered Manager (when she 
arrived on shift) actually visited Mr Banks’s flat to see for themselves the damage to the medicines 
cabinet, an omission that we agree was regrettable. Whilst the Team Leader had not received 
formal investigation training, the Registered Manager had received such ‘Event Management’ 
training and ideally would have followed up on the initial report with a more thorough investigation 
of her own and would have certainly taken the time to look at the damage in the flat herself. 

We are at present in the process of developing our management training programmes and this 
includes Event Management training as part of our onboarding programme for Team Leaders, 
Care Coordinators and others. The new programme will roll out during 2021. 

In the meantime, we will communicate to ECS managers during February 2021 that they must at 
the very least review investigations carried out by others at their schemes to ensure that they are 
adequate. 

I trust that this letter addresses your concerns and we once again offer our sincere condolences to 
Mr Banks’s family.  

Please do not hesitate to contact me if I can provide any further information to assist you. 

Yours sincerely 

Director of Policy and Communications