Heather Beatrice Planner · Prevention of Future Deaths report

On 4th April 2019 I commenced an investigation into the death of Heather Beatrice Planner, aged 87 years. The investigation concluded at the end of the inquest on 20th November 2019. The narrative conclusion of the inquest was that Mrs Planner died from natural disease to which a stroke caused by the effects of not receiving her prescribed anticoagulation contributed more than minimally.

The medical cause of death established was:

1a Large bowel ischaemia leading to gastrointestinal bleed
1b Peripheral vascular disease
2. Left frontoparietal lobe infarct, atrial fibrillation, ischaemic heart disease, hypertension

The circumstances were that Mrs Planner died on 1st April 2019 at Wycombe Hospital as a result of a gastrointestinal bleed. This was against a background of large bowel ischaemia and in the context of a stroke which occurred after Mrs Planner had not received her prescribed apixaban anticoagulation at home over the two days prior to her admission to Stoke Mandeville hospital on 27th February 2019.

Carewatch (Mid Bucks) were the providers of individual carers who administered medication from a dossette tray which was labelled for a different patient and which contained the medication for that other patient, rather than Mrs Planner’s specific medication.

(1) Changes to an individual patient’s medication are emailed to carers and a new prescription (MAR) chart is issued but there is no procedure in place to ensure that individual carers have read and specifically acknowledged any medication changes.

(2) 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.

(3) There does not appear to be any process for individual carers to sign to acknowledge having read and implemented a patient’s care plan in the patient’s log book.

(4) There does not appear to be a system for recording on a patient’s records specific medication instructions or changes to medication which might have been given or taken by mobile phone.

(5) There does not appear to be any electronic system or record to enable carers to access a patient’s medication history, the records at the patient’s home being only paper records.

(6) 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, since Carewatch had not procured the original paper patient records from Mrs Planner’s home address at any stage during their investigations or prior to the inquest hearing. This may have compromised the ability to assess the accuracy of records to which the individual carers had access, any impact that may have had upon the medication error, or any learning to arise in the context of record keeping and application of medication and care plan requirements by carers.