Shahida Khan

Dear Mr Pegg 

Regulation 28: Report to prevent future deaths in relation to Shahida Khan 

I am responding to the Regulation 28 Report issued on 24 April 2024 following the inquest into the 
death of Shahida Khan (‘Ms. Khan’) on 17 December 2022. The inquest concluded on 23 April 
2024.   

Voyage Care (‘Voyage’) deeply regrets the death of Ms. Khan and the distress this has caused her 
family.  Our staff at the care home were also very saddened by her passing.  

The concerns raised by you at paragraph 5 of your PFD report are as follows:  

1)  All  of  the  deceased's  medications  were  administered  by  care  home  staff.  The 

medications were kept secure in a locked medicine chest in an office.  

2)  The  deceased  was  administered  with  toxic  and  fatal  quantities  of  valproic  acid, 

3) 

lamotrigine and paracetamol. It cannot be ascertained how this happened.   
In the absence of an explanation there is a risk of a further recurrence where those in 
the care of the staff are administered toxic and fatal quantities of medications.  

Your concerns touch upon medication storage, medication audit and medication administering 
competencies.  I  can  confirm  that Voyage has established policies and  procedures  in place to 
deal  with  medication  storage,  medication  audit  and  medication  administering  competencies, 
and these  were in place at  the  time  of Ms. Khan’s  death.  Extracts of these have already been 
provided to you. The policies and procedures are robust and are subject to audit. Staff are trained 
in all of the areas referred to both on induction and annually.  

Until 19th April 2024 Voyage was unaware of the confirmed Medical Cause of Death for Ms. Khan. 
The investigations into Ms Khan’s death undertaken by Voyage immediately following Ms. Khan’s 
death were carried out without knowledge of the postmortem or toxicology findings.  

In order to address your specific concerns and those matters which came to light at the inquest 
on  23  April  2024,  specifically  regarding  medication  levels  found  on  postmortem,  Voyage 
conducted a further investigation specifically focused on medication storage, medication audit 
and  medication  administering  competencies  at  the  care  home  where  Ms  Khan  resided.  This 
investigated confirmed:  

I. 

II. 

III. 

Ms.  Khan’s  medication  was  stored  in  a  locked  cabinet  and  in  accordance  with  our 
policies and procedures.  
Medication  audits  for  the  care  home  were  completed  by  the  former  Registered 
Manager on 1st December 2022 (for the month of November 2022) and 29th December 
2022 (for the month of December 2022).  The medication audits completed confirm 
that the care home was compliant in all areas and there were no discrepancies in the 
medication stock count in either month.   
Ms Khan’s medications were administered by support staff and when she went home 
to stay with her family, medications were provided to them to administer in accordance 
with her prescriptions.  

In addition, having received copies of the postmortem and toxicology reports on 19 th April 2024, 
we  instructed  an  independent  Consultant  in  Chemical  Pathology  and  Forensic  Toxicology  to 
independent 
review  the  evidence  following  our 
Toxicologist’s investigation and our own medication investigation did not determine the origin of 
any overdose. In the circumstances we have referred the matter to the Police. Whilst medication 

investigation.  Regrettably,  the 

internal 

 
 
 
 
 
 
 
 
 is usually given to the People we Support by staff, the investigation by the Police will no doubt 
have  to  consider  the  possible  involvement  of  third  parties,  for  example  other  visitors  to  the 
service. We have confirmed to your office that the matter has been referred to the Police and, in 
those circumstances, I would respectfully request that this response should not be published 
until the Police have completed their investigation, to avoid any risk of compromising this. Until 
the Police complete their investigation it is difficult to comment further, and we will be advised by 
them  as  regards  next  steps  including  any  steps  which  should  be  taken  to  address  matters  of 
concern  at  paragraph  5  of  the  PFD  Report.  In  liaison  with  them,  we  will  also  take  the  steps 
necessary  and  appropriate,  to  manage  staff,  which  may  include  suspension  pending  the 
conclusion of investigations. 

As  previously  stated,  we  have  found  no  evidence  of  misadministration  by  our  staff,  having 
completed rigorous medication counts as part of our investigation.  We have, however, taken a 
number of further steps to reduce the risk, insofar as is possible, of a Person We Support being 
administered toxic and fatal quantities of medications. These include: 

▪  We have reviewed the care of all residents at the home and their care plans, including, 

where relevant, protocols for the administration of rescue medication. 

▪  We have reviewed the medication training in the home and are in the process of renewing 

medication training for all staff at the home.  

▪  We have commissioned an independent pharmacist to review our policies, procedures, 
training content and audits.  Whilst not as a direct result of this sad circumstance, it is 
relevant to our response as a reflective and responsible provider. 

▪  A  further  related  action  is  the  planned  implementation  of  an  electronic  Medication 
Administration System across the organisation.  This is part of a larger programme of work 
designed to provide more comprehensive oversight of the delivery of care to residents, 
including the administration of medication.  

We will be keeping matters under close review and implementing all and any changes that appear 
to be necessary as a result of the Police investigation. We understand that the coroner’s office is 
also in direct contact with the Police regarding this matter.   

Thank  you  for  raising  your  concerns.  I  hope  that  the  content  of  this  letter  provides  sufficient 
assurance that we have taken appropriate action following the death of Ms. Khan and in response 
to information as it has become available to us. We continue to work to improve the service we 
provide to the People we Support.   

Yours sincerely, 

Chief Operating Officer (previously Interim Chief Executive Officer) 
Voyage Care