Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0369, written 21 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jul 2025 |
|---|---|
| Reference | 2025-0369 |
| Deceased | Christopher O’Donnell |
| Coroner | Ian Singleton |
| Coroner area | Wiltshire and Swindon |
| Category | Alcohol, drug and medication related deaths |
| Organisation named | Avon and Wiltshire Mental Health Partnership NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
HM Senior Coroner for Wiltshire and Swindon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive/Managing Director Home Group Limited One Strawberry Lane Newcastle-upon-Tyne Tyne & Wear NE1 4BX CORONER lam lan Singleton, Area Coroner for Wiltshire and Swindon CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 14 December 2023 | commenced an investigation into the death of Christopher John O'Donnell and | opened an Inquest into his death on 30 September 2024. On 18 July 2025 | concluded Christopher’s Inquest. | found the medical cause of death was as follows: 1a. Asphyxia due to Airway Obstruction by Vomit 1b. Drug Toxicity By way of a conclusion, | recorded a short form conclusion of drug related and as to when where and how (by what means Christopher came by his death) | provided the following: Christopher John O'Donnell (Chris) lived in supported living accommodation at Canal House, P| Chris had a past medical history which included drug and aicohol abuse, together with mental health issues, for which he had been prescribed medication. In November 2023, Chris admitted that he had not taken his medication for some months, leading to a noticeable return of his paranoia and persecution complex, resulting in Chris believing wrongly, that it was not safe for him to remain at Canal House., but he had no alternative accommodation to go to. On the 12 December 2023, Chris was found deceased in a communal lounge at Canal House, having consumed a substantial, but not fatal amount of his methadone medication, that he had been allowed access to, notwithstanding the recognised risks, which had led to him vomiting and being asphyxiated by his airway being obstructed by vomit. CIRCUMSTANCES OF THE DEATH Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 Having considered the evidence, | found the following facts in relation to the circumstances of Chris’ death. Chris’ death was drug related in that the post-mortem confirmed that he had taken a substantial, but not necessarily fatal amount of his prescribed Methadone that led to his central nervous systems including breathing and heart rate being slowed down. Common side effects are nausea and vomiting with the vomit being aspirated causing obstruction of Chris’ airway leading to asphyxia and death. | found that the following factors more than minimally contributed to his decision to take that medication. Firstly, that Christopher had suffered for a number of years with drug and alcohol abuse and with his mental health, for which he had been prescribed medication. Christopher had stated that he had stopped taking the medication leading to a return of paranoia and a persecution complex leading to Chris believing it was not safe for him to live at Canal House, an but Chris did not have any alternative accommodation to go to on 12 December 2023. Secondly, that Chis had a stockpile of Methadone in his room which he had access to as from 11 December 2023 and consumed one half of, leading to the sequence of events that caused his death, despite the risk of that stockpile, being recognised beforehand. During the course of the Inquest, | heard evidence from a Mental Health Support Worker at Canal House that she had had a discussion with! Christopher's Recovery Co-Ordinator with the local Substance Misuse Team, that Chris had a stockpile of Methadone medication in his room and that she was concerned at the risk that it posed. In evidence J said that she had spoken to Christopher about agreeing to giving up the medication and returning it toa pharmacy but as he had not consented, that had not happened. She also believed that she had raised it with her manager, but the view was, that as Christopher had not consented to the medication being confiscated there was nothing they could do. CORONER’S CONCERNS The issue that | had was that there appeared to be no basis for or consideration of the supported living accommodation provider, taking action to provide safeguarding for Christopher by removing the excess medication so that it was not within his control. | was informed > a ht the supported living accommodation provider did not allow staff to hold any medication even if it was done with the intention of providing safeguarding to someone, who by all accounts, was undergoing a mental heaith crisis. | would hope that the organisation will review its policies as to what action (if any) it can take when itis made aware of a risk to a resident, rather than to only take action with the resident's consent. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 15 September 2025. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Person, Family of Mr O’Donnell Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP! 1DP Tel 01722 438900 lam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person whom she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated 21 July 2025 Signature Singleton HM Area Coroner for Wiltshire & Swindon Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
13th October 2025 Dear Mr Singleton, Response to Regulation 28 Report Inquest into the death of Christopher John O’Donnell I am writing in response to your Regulation 28 Report to Prevent Future Deaths (“PFDR”), dated 21 July 2025, to outline the actions taken by Home Group Limited (“Home Group”) to address your concerns. Home Group has taken this incident, and your findings, very seriously and is committed to continuing to improve the supported housing services we provide. We have taken a proactive approach in addressing your concerns immediately following the conclusion of the inquest, and following receipt of your PFDR, including engaging in consultation with key agencies with whom we work in close partnership to support our service users. All policies referred to in this response are available on our website1. 1. Home Group Limited Home Group is a registered social landlord providing general needs social housing, supported housing and social care services across England and Scotland. We operate over 280 supported housing services across more than 6,700 supported homes in England. Most of our services, including Canal House at which Mr O’Donnell resided, are supported housing services for people experiencing homelessness, substance misuse issues and / or low to medium level mental health needs. These services offer short term (usually up to two years), low level housing related support. Supported housing services are regulated by the Regulator of Social Housing. 1 Home Group | Policies Home Group’s services in the Swindon area, encompassing Canal House, are not commissioned by the local authority to provide support to service users in relation to the handling or administering of medication. In this situation, the responsibility for this would lie with Change Grow Live (“CGL”). The support provided as part of Home Group’s supported housing services includes: Access to and retaining permanent housing; Sustaining a tenancy; Accessing employment or training; Appling for welfare benefits and managing finances; Accessing specialist services provided by other agencies, such as health care and substance misuse services; Building and maintaining positive personal relationships; and Developing day to day living skills such as cooking and cleaning, with a view to moving onto independent accommodation. The attached document provides further information about our Living Independently, Feeling Enabled (“LIFE”) practice model and the principles we work to in delivering our services. 2. The Coroner’s concerns As detailed in your PFDR, we understand that you are concerned that action was not taken by Home Group in removing stockpiled medication from Mr O’Donnell’s room in circumstances where concerns had been raised both internally and externally that he was stockpiling prescribed medication. When addressing your concerns, it is pertinent to consider the background to Mr O’Donnell’s access to and use of prescribed medication whilst residing at Canal House. The supported housing provided at Canal House is not mandated to provide medication management services to its service users. Therefore, in circumstances where a service user is deemed to have capacity, Home Group does not have the authority to interfere with that service user’s lawfully held prescription medication. Mr O’Donnell was prescribed Methadone; this is a Class A controlled drug under the Misuse of Drugs Act 1971, Schedule 2, Part 1. Home Group is not permitted to lawfully retain or store controlled drugs at its supported housing premises, including at Canal House. Where controlled drugs are prescribed, they may be kept lawfully at Home Group’s supported housing premises by the recipient of the prescription only. Having reflected on your findings, Home Group has taken the following action in response to your concerns. 3. Working together with other agencies Home Group are committed to working in partnership with key agencies to mitigate the risks associated with the stockpiling of prescribed medication in supported housing settings, within the limits of what is legally permissible and within our service remit. Following receipt of your PFDR, the Operations Manager at Home Group wrote promptly to key agencies in the Swindon area: Park Lane Pharmacy (the local pharmacy to Canal House), Change Grow Live (“CGL”), and the Mental Health Team, Avon and Wiltshire Mental Health Partnership NHS Trust (“AWMHP”) based at Chatsworth House, Swindon. Contact was made in an effort to obtain these agencies’ views on how a collaborative working approach could be improved to better safeguard service users who are at risk of harm from stockpiling prescribed medication, in particular controlled drugs such as Methadone, and in circumstances where Home Group is made aware of said risk. Agencies were invited to share their understanding of the circumstances in which stockpiled prescribed medication can be retrieved from a service user / their room, whether there is any legal basis for this, and what practical arrangements can be put in place to facilitate removal in circumstances where concerns have been raised, including specifically what, if any role Home Group can play in this. a) Mental Health Team On 21 August 2025, a written response was received from the Clinical Lead in the Swindon Locality who provided a summary of the policies and procedures governing AWMHP’s approach to managing medication for service users. Whilst these policies and procedures do not specifically apply to the service remit of Home Group’s supported housing services, such as those provided by Canal House, they provide helpful guidance in relation to the local Trust’s approach to medication management. The Mental Health Team has advised that patients own drugs (“PODs”) remain the legal property of the person for whom they were dispensed. Generally, PODs should not be used or disposed of without a service user’s or relatives’ consent, unless a best interest decision is required (in accordance with the Mental Capacity Act 2005), and all such decisions should be documented. Home Group continues to consult with mental health services to identify what further practical support can be provided by supported housing services in the event that concerns are raised about a resident stockpiling their own prescribed medication. b) Change Grow Live On 22 August 2025, the Operations Manager attended a call with CGL to discuss the concerns raised in your PFDR and to agree a clear plan in terms of partnership working moving forward, particularly in circumstances where concerns in relation to the stockpiling of medication by a service user are raised by either Home Group or CGL staff. It was agreed with CGL that as part of expectations moving forward, any concerns regarding the stockpiling of medication by a service user will be reported by Home Group directly to the relevant local pharmacy who can then either arrange for the collection of the medication or instruct CGL to manage removal. We also agreed that matters concerning the stockpiling of medication should be dealt with at manager rather than support worker level, and that the guidance for support workers will be to escalate any concerns to management. To support this, we are looking to implement a risk assessment checklist as a useful resource for support workers. This checklist is addressed in more detail below. Home Group is committed to ensuring a close working relationship with CGL is maintained moving forward. As part of this, representatives from Home Group will attend the monthly drop-in session for professionals held by CGL. In addition, CGL have agreed to deliver training to the Home Group team based in the Swindon area in relation to controlled drugs. To support our joined-up approach with CGL, they have agreed to provide an example working protocol regarding medication management for service users which is in line with those shared between CGL and other partner agencies. Once received, Home Group are keen to agree and implement a tailored working protocol with CGL that is specific to the supported housing services provided by Home Group. c) Park Lane Pharmacy On 25 September 2025, verbal feedback was received from the pharmacy who have advised that Home Group staff working in supported housing services can raise any safeguarding concerns in relation to the stockpiling of prescribed medication directly with the pharmacy and/or with the medication prescriber i.e. CGL. Guidance for staff around raising concerns with the pharmacy and/or prescribers is to be developed in conjunction with the risk assessment checklist addressed below. A written response from pharmacy management is anticipated in due course and Home Group is committed to continuing to consult with the pharmacy moving forward. 4. Improvements in services a) Multi-agency approach Home Group is committed to being a part of a multi-agency approach to better assess and manage the risks around the stockpiling of prescribed medication and the associated safeguarding concerns. Our Safeguarding Policy sets out our commitment to share information and work in partnership with other agencies to reduce risks to vulnerable adults and children. We work with statutory and non-statutory agencies to help identify and manage risks to service users and the local community. We also work with service users and those who support them to identify appropriate safety measures that reduce or manage risks, in line with their preferred choices. In our supported housing services, risk assessment and risk management form an integral part of support planning, overarched by our Support Practice Policy. Providing safe and properly maintained housing is a key factor in safeguarding our service users. b) Planned policy review Home Group is planning a full review of its Support Practice Policy. This policy sets out our overall approach to supporting customers in supported housing services, including our commitment to delivering safe services and effective risk management. The policy sets out the standards we expect our services to achieve in relation to all aspects of support including handling referrals and admissions to services, assessment and support planning, risk management, working in partnership with other agencies and moving on from services. The review of the policy will commence in Autumn 2025, with the updated policy being presented for approval by Home Group in Spring 2026. We plan to consult widely with customers, partner agencies and other stakeholders as part of this review and we will carefully consider the findings of the inquest into Mr O’Donnell’s death as part of this consultation, especially in relation to updating our approach to risk assessment and risk management. We are currently in the process of reviewing and refreshing our LIFE support practice model to ensure that it is effective in facilitating compliance with the practice standards set out in the Support Practice Policy. Our review is a focussed on strengthening our approach to risk assessment and risk management, especially when working with individuals thought to be at risk of self-harm or suicide. We are also planning to carry out a concurrent review of our Tenure Policy, which includes standards around the enforcement of tenancy terms and conditions. This policy includes standards relating to house rules and access to customers’ rooms in specific circumstances. Consideration is being given to updating our Tenure Policy to allow Home Group staff and partner agencies working with a service user to access a service user’s room in circumstances where there is evidence of stockpiling, and access has been approved by a manager in accordance with the prescribed risk assessment mentioned below. c) Risk Assessment Checklist As part of Home Group’s wider planned policy review, we plan to review and update risk assessment templates and risk management plans, alongside training resources and quality assurance checks, to support accurate and timely risk management where there are concerns in relation to stockpiling medication. We are in the process of developing a ‘Risk Assessment Checklist’ specific to the stockpiling of medication in supported housing services. A draft checklist is enclosed with this response which remains in development. Our intention is to pilot the checklist with operational colleagues and to develop guidance and training for staff to sit alongside it. The checklist acts as a prompt for staff to alert their manager and partner agencies to safeguarding concerns around the stockpiling of prescribed medication. As mentioned, guidance will be developed alongside the checklist with a link to said guidance inserted directly into the checklist for staff to easily access. The checklist is intended to be user friendly and act as a tool for staff to document their concerns about a customer, which can then be discussed with their manager and partner agencies, and appropriate action taken. The expectation is for the checklist to be used as a tool for staff who have concerns in relation to the stockpiling of prescribed medication where customers are managing their medication independently and are not receiving support from Home Group in relation to medication management. Where there is evidence that a customer is stockpiling medication, the checklist alerts staff to discussing this as a safeguarding risk with partner agencies, including the prescriber and relevant pharmacy. Managers will have oversight of the checklist as part of our quality assurance approach. Staff are required to review the checklist with their manager and to document what was discussed and any actions agreed. The checklist will be accompanied with guidance and training for staff around how to complete the checklist and the actions to be taken in circumstances where a staff member has potential safeguarding concerns around a customer stockpiling prescribed medication in a supported housing setting. Staff will be able to access the supporting guidance directly from the checklist which will be made available to all staff via SharePoint. The checklist forms part of a broader review of Home Group’s LIFE support practice model and Support Practice Policy. Home Group have a sharp focus on risk assessment management and plan to further review how the checklist sits as part of the wider support practice framework. The ongoing policy reviews, as detailed above, encompass a broader consideration of Home Group’s assessment and management of risk with the checklist forming part of a wider initiative to help facilitate improved risk assessment and management. d) Virtual clinical hub Home Group have introduced a virtual clinical hub that provides clinical advice and guidance to all supported services that do not already have a Home Group clinician attached to them. This includes accommodation based, community based and housing management services. The virtual clinical hub has been up and running for approximately one year and aims to provide: Support to embed Psychologically Informed Environments (“PIE”) within supported housing services; Support to embed the LIFE framework within services; Support to look at risk in different ways and to develop confidence in using a positive risk-taking approach; Support for colleagues during ongoing crisis intervention with individual customers; Support in improving services to meet contractual needs; Support to analyse incidents, lessons learnt and develop positive changes; Support to upskill teams and access training and development; and Support to access and work with external agencies to enhance customer pathways and break down barriers. Home Group are committed to continuing to consult with partner agencies to encourage a multi-agency approach to identifying, assessing and managing the risks presented to service users by the stockpiling of prescribed medication. We have sought guidance from partner agencies on how to seek intervention where there are concerns about a service user’s safety and this consultation will remain ongoing. Yours sincerely, Executive Director of Customer and Communities
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