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[CLKD]

An 87-year-old woman died after her carers gave her the wrong medication, a coroner was told.

Heather Planner, from Butler's Cross in Buckinghamshire, died at Wycombe Hospital on 1 April from a stroke.

Senior coroner Crispin Butler heard three staff from Carewatch Mid Bucks had failed to spot tablets handed over by the pharmacy were for a male patient.

Mr Butler said action should be taken to prevent similar deaths.

A hearing in Beaconsfield on Thursday, where he issued a Prevention of Future Deaths report, followed an inquest in November.
In the report he said he was told at the inquest that the carers from Carewatch Mid Bucks gave widow Mrs Planner the wrong medication four times a day for two and a half days.

The hearing in November heard the mother of one suffered a fatal stroke because she did not receive her proper apixaban anticoagulation medication.

[CLKD]

How do we stop this happening?  Surely carers should not be giving essential medication but this should be administered by the District Nurses?  But to give a woman medication prescribed for a man  and not noticed by 3 'carers'!

When I think how Staff at my Surgery who have known me for 30+ years but ask my address when I pick up my script  .

Perhaps Carers should be interviewed by the Pharmacist who ought to check that they have the correct medication for the correct Client B4 the pills are handed over?  Even taking a Photo of the Client that they are picking up for and also, having to pick up from 1 Pharmacist rather than being able to go to the nearest with a Script?

[Tc]

Clkd. Have you seen this

https://www.nursingtimes.net/news/community/whistleblowing-district-nurse-different-person-after-unfair-dismissal-17-02-2020/

[CLKD]

Sadly this happens in many professions  despite there being Unions present in many 

How can we prevent the fact that the carers gave this woman the incorrect medication?

[Woodlands]

Hi there.
Having been a district RGN nurse in a previous career it is impossible for a district nursing team to take on all patients needing medication.
Errors here by pharmacy checking and safe administration of meds by the carers.... Thats down to training from their agency they work for.
Once saw a vial of insulin labelled for the right patient but was pork not human insulin.....
District nursing teams are under such pressure... Their books don't close when beds are full like a ward does... Sometimes seeing as many as 20 patients in 8 hour shift to include all care, travel, referrals and admin....
Hard work indeed
Woodlands

[CLKD]

Tnx Woodlands.  So how can this type of situation be prevented?  Should we all contact our local pharmacy to discuss this sad situation?

[Tc]

Sadly the district nurse who raised it (my link,) ended up getting sacked for doing so. 😞

[Woodlands]

Hi there.
These days its too many managers in the NHS dictating to the field workers this n that without understanding the pressure on staff... Budgets are tight, i use to do some admin through a secure system at home on my work laptop all unpaid of course... Record entries logged in the same day you work was a nightmare task.
Way to protect your own loved ones with medication.... Ensure the pharmacy always dispense into blister packs.... Exact medication give at correct times happens then
Its hard but true
Woodlands

[Woodlands]

Hi Rockhopper.
Yes so so sad re selling off beautiful building and using remote working or hot desks where i have witnessed staff wearing ear defenders to ensure they have peace to write essential details reports.
I retired almost 5 years ago and I'm so much better for it.... My DS loss led me to reevaluate... I have now a great tto job xx

[Tc]

When my wife was ill she insisted on taking responsibility for her own medication and didnt like me interfering. .

Upon release from hospital one time, she became increasingly  drowsy over the next few days. It became scary.when  I couldnt rouse her.  I called an ambulance.  Nothing had changed meds wise but whilst I was waiting I got all her meds together .  . The discharge form and hospital pharmacy had prescribed an anti emetic which was twice the strength of her usual dose. It did say on the box once a day in very small writing on the box and she obviously missed that. And had taken her usual 2 per day.

The upshot was  the ambulance guy had to look up on an app whether it was a toxic dose and said it was considered a possible overdose. 
It's not an unserstatement to say that it could have compromised her breathing and quickly become fatal.  We ended up back in hospital.

She obviously missed the fact that the dose and frequency had changed but the box and tablet looked the same and it wasnt clear enough on the very small writing on the label. It certainly wasnt pointed out to us when we were given the meds.

I took over from then on. I had a typed list of all her meds.  I queried  any dose increases or changes and checked and double checked.  Even after that she was prescribed things she shouldnt have had or wrong doses. And as she became more Ill it wouldve been increasingly hard for her to do that for herself.   

[CLKD]

It's really easy to miss information.  Packs looking the same.  Prescriptions not checked against what has been given previously .......