MEDICATION


Medication Mismanagement


A Shropshire care home and manager has been fined after medication errors


put residents at risk of ‘serious harm’. We find out more about the dangerous consequences of poorly managed drugs.


A Shrewsbury care home owner and its former manager were fined over £50,000 at Telford Magistrates’ Court last month after admitting they failed to provide safe care to a service user.


Dennis Wootton died at Coton Hill House care home on 11th April last year following errors in the admission of his anti-coagulant drug.


According to the home’s records Mr Wootton was not prescribed this medicine for up to 30 days before his death after supplies ran out, and the home failed to order more.


A post mortem examination revealed he died as a result of a pulmonary thromboembolism and deep vein thrombosis.


Although Mr Wootton’s death could not be directly linked to the medication errors the CQC found that these omissions and other similar mistakes had put residents at risk of ‘severe harm’.


Mr Wootton had been prescribed anti- coagulant medication on his discharge from the Royal Shrewsbury Hospital,


“It is vital that


care services accurately record the medicines


people are given and that, when these run out,


they make every effort to replenish stock’’


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where he had been taken after falling ill at the home in February 2015.


Jenny Ashworth, prosecuting, told the court that when CQC inspectors looked at Mr Wootton’s medication records there were a number of omissions and errors.


The dosage for his anti-coagulant drug was inaccurately recorded, as was the length of time for which he should be given the drug.


Ms Ashworth explained that whilst, while Mr Wooton’s death was not a direct result of not receiving this medication, people living at Coton Hill House had been put at risk because of the home’s management and recording of the medicines people received.


Inspectors found repeated failures by the home in ensuring anti-depressants, pain relief and medication to treat Alzheimer’s disease and manage a thyroid disorder were in stock. Allergy information was not recorded and the home failed to consistently and accurately record the times medicines were administered, creating a risk of overdose.


There were also several failures to record the strength of medication given to people and medicines went missing from stock.


Deb Holland, Head of Adult Social Care Inspection for CQC in the Central region, said: “While we welcome the fact that both the provider and manager accepted responsibility in this case, we would always rather not be in the position of having to take action because vulnerable people have been failed by those providing their care.


“We appreciate how distressing this has been for Mr Wootton’s family and, like them, hope this case prompts other care home operators and managers to review their medicine management systems to better ensure people’s safety.


“It is vital that care services accurately record the medicines people are given and that, when these run out, they make every effort to replenish stocks to ensure people continue to receive the right treatment and are not left at risk of harm. Our inspectors were shocked by what they found at Coton Hill House.


“It was the serious and repeated failures in the home’s management of medicines that led to CQC’s prosecution of the provider, Coverage Care Services Limited, and the home’s registered manager.


“As the registered provider and home’s manager, Coverage Care Services Limited and Alison Gough had a specific legal duty to ensure care and treatment was provided in a safe way. Following Mr Wootton’s death we found they had failed to do this by not ensuring medicines were managed in a safe way.


“If we find that a care provider has put people in its care at serious risk of harm, we will consider holding them to account using our powers to prosecute.”


Coverage Care Services Limited was fined £50,000 plus a £120 victim surcharge and one of its former managers, Alison Gough, was fined £665 and a £66 victim surcharge in a prosecution brought by the Care Quality Commission.


www.tomorrowscare.co.uk


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