Kumbulani Mtombeni

Care Outlook 
2-10 Laurel Grove, 
Sydenham, London 
SE26 4JY 

info@careoutlook.co.uk 
www.careoutlook.co.uk 

By Email and Post: 

Coroner Lydia Brown 
Area Coroner for West London 
West London Coroner Service 
25 Bagleys Lane 
Fulham 
London SW6 2QA 

Dear Coroner Lydia Brown 

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

06 October 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. 

3. 

  was  receiving  4  calls  daily  to  support  with  personal  care,  meal  preparation  and 

medication.  

  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 
and continued on discharge from hospital. 

 home prior to his hospital admission 

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 
deterioration which would suggest medication had not been administered. 

  of  a 

    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 
 flat and the key locked in the office.  Care workers signed for the keys 

locked safe in 
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 
  This was agreed to reduce the amount of 

 and a second delivery of 

delivery  
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 

Yours Sincerely, 

Managing Director 

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