Following an investigation into the security and access
to Schedule 4 and Schedule 8 drugs at Beaumont Care Aged Care
Services ('Beaumont Care'), the Office of the Health
Ombudsman (Queensland) ('Ombudsman') found the aged care
provider had remedied deficiencies in their medication management
system that had been exploited by a former drug-addicted
On 28 October 2014, the Ombudsman was contacted by an
unregistered provider who claimed to have formerly worked at the
Kippa-Ring and Redcliffe facilities of Beaumont Care. The
unregistered provider advised they had stolen schedule 8 drugs
(Endone, Ordine) and schedule 4 drugs (Temazepam, Oxazepam,
Diazepam) from the drug safe and the drug room which they were able
to access. The drugs were also obtained from the leftover drugs of
patients who had died in order to fuel the unregistered
provider's drug addiction.
The Ombudsman commenced an investigation at both facilities into
the issues raised by the unregistered provider on 12 November 2014.
When notified of the investigation, Beaumont Care acknowledged they
had conducted two internal investigations into missing controlled
drugs during the relevant time period, although the culprit had not
been definitively identified. Beaumont Care provided the Ombudsman
with documentation of their policies which included a medication
management policy, medication framework document, medication
administration competency checklist and audit documents.
The Ombudsman assessed the system for management of medications
with three issues in mind:
Whether adequate policies, procedures and protocols
were in place
The Ombudsman noted internal investigations undertaken by
Beaumont Care following the incidences identified and remedied a
number of contributing factors to the thefts, including:
The keys to the controlled drug safe had been given to an
unregistered provider on one occasion;
The keypad to the safe had four worn numbers on it, clearly
identifying the four numbers regularly used in the pin; and
The door to the medication room was damaged such that the lock
would not catch properly.
The evidence indicated that the unregistered provider exploited
these deficiencies in the system to gain access to the medication
room and controlled drug safe to misappropriate the
Beaumont Care then implemented corrective measures which
included changing the pin code regularly, having the safe changed
to a key lock safe and fixing the broken door to the medication
room. These actions in conjunction with the existing governance
processes were considered sufficient to mitigate the risks of the
Whether staff were compliant with the policies,
procedures and protocols
Based upon the evidence at hand, the Ombudsman concluded there
was no widespread training issue or disregard by staff for
policies, procedures and protocols. Non-compliance by one staff
member, believed to be the initial complainant, had been the
subject of investigation by Beaumont Care and was adequately
addressed prior to that employee's resignation.
Whether systematic improvements should be
The Ombudsman considered the corrective actions taken by
Beaumont Care to ensure adequate security of the medication room to
be an appropriate response to mitigate the risk of reoccurrence.
Notably, Beaumont Care had undergone an Australian Aged Quality
Agency audit which reported full compliance.
Based upon the above grounds, the Ombudsman formed the view that
no further action be taken under section 33(1)(a)(iv) of the
Health Ombudsman Act 2013 (Qld) as the identified issues
were resolved or appropriately finalised.
Having medication management policies in place will not prevent
an opportunist from taking advantage of lapses within security
regimes. The Beaumont Care example is a reminder to all health care
providers to regularly audit and review the policies in place and
to assess for potential gaps in security.
The content of this article is intended to provide a general
guide to the subject matter. Specialist advice should be sought
about your specific circumstances.
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