An 87 year-old woman has died after her carers gave her the wrong medication, according to a coroner’s report.
Heather Planner, from Butler’s Cross in Buckinghamshire, died at Wycombe Hospital (pictured) on April 1 as a result of a gastrointestinal bleed and after suffering a stroke.
Senior coroner Crispin Butler heard that three staff from Carewatch’s Mid Bucks franchise had failed to spot tablets handed over by a pharmacy were for a male patient.
As a result, the carers gave Mrs Planner the wrong medication four times a day, over two and a half days.
A post-mortem found that it was not the wrong tablets that led to her stroke, but the lack of her correct medication that caused it.
In a Prevention of Future Deaths report, which was issued during a hearing last week, the coroner said there is a risk that future deaths could occur unless action is taken.
He said that an inquest, which took place in November, raised a number of areas for concern, including that there is no procedure in place at Carewatch Mid Bucks to ensure individual carers have read and specifically acknowledged any medication changes.
Evidence also revealed that it is unclear what additional measures or cross-checking have been introduced to prevent a subsequent carer, who is attending a patient, from inheriting a medication error from an earlier attendance and repeating that error.
It also does not appear to be any process for individual carers to sign to acknowledge having read an implemented a patient’s care plan in the patient’s log book, the report said.
The inquest also heard that Carewatch Bucks does not appear to have an electronic system to enable carers to access a patient’s medication history.
The coroner added: “There is a specific concern in Mrs Planner’s case about the robustness of the subsequent Carewatch investigation and any learning that would arise to prevent incidents in the future.”
A spokesman for Carewatch Mid Bucks said the company wanted to “reiterate and express our deepest condolences to Mrs Planner’s son and all of her family and friends”.
The spokesperson added: “Carewatch (Mid Bucks) was an Interested Person at the inquest into Mrs Planner’s death and we participated fully, answering all of the questions put to us by the coroner and her family.
“The Care Quality Commission (CQC) carried out an investigation into this incident prior to the publication of their latest inspection report on our service in November 2019, when we were rated as ‘Good’.
“In their report they acknowledged that we had reviewed the way that we support people with medicines; they also acknowledged that ‘all staff had received additional training to refresh their skills’ and that we had carried out our own internal investigation to ‘ensure the risk of a similar incident was minimised’.
“Given that we are now in the process of addressing certain concerns raised by the coroner, it would not be appropriate to comment further at this time.”
Deborah Ivanova, deputy Chief Inspector (London and South) at CQC said: “This was a tragic incident and we offer our condolences to Mrs Planner’s family at this time.
“After the death of Mrs Planner, we inspected Carewatch Mid Bucks on 4 and 5 April 2019. Our inspectors found that ‘following a breakdown in staff observing the provider’s policies and procedures, which resulted in a person not receiving their prescribed medicines, the service reviewed the way they supported people with medicines’ to reduce any likelihood of a similar situation happening again. At the time of inspection we were assured that robust mechanisms were in place and people were receiving safe care.
“We received a copy of the coroner’s report and while there are no recommendations for CQC we will continue to monitor Carewatch Mid Bucks to ensure people are receiving consistently good quality care.”