Geoffrey Peter Banks · Prevention of Future Deaths report

On 23/01/2020 I commenced an investigation into the death of Geoffrey Peter Banks, aged 64. The investigation concluded at the end an inquest on 24th November 2020.
The cause of death was :-
1a.Acute myocardial infarction.
1b. Coronary artery thrombosis with atheroma.
2. Co-codamol; diabetes mellitus type 2.

The conclusion of the inquest was :-
The deceased died from a heart attack. A self-administered overdose of medication 8 days earlier contributed to his death. It was not possible to determine whether the overdose had been accidental or deliberate.

The deceased was 64 years of age and had a medical history which included heart attack, coronary artery by-pass grafting, pacemaker, stroke, diabetes and dementia which had worsened recently. He lived in assisted accommodation and was visited 4 times per day by carers, principally to assist him with his medication which was kept in a locked kitchen cupboard in his flat. Carers visited at around 07.00 hours on the 1st January 2020 and found that he had pulled open the locked medicine cupboard and had taken 44 co-codamol tablets. He was admitted to the Royal Stoke University hospital where he was treated for pulmonary oedema and mixed overdose. A blood test done on admission showed a paracetamol level at 91mg/l. There was no real evidence of liver damage but there was clear indication of heart failure consistent with his coronary condition. He had clinically improved from the overdose and he did not need any further treatment for that. On the 8th January 2020 he became unresponsive as he was being helped into a chair. Resuscitation attempts were unsuccessful and he was certified dead at 08.20 hours. Post mortem examination found the cause of death to be an acute heart attack. The co-codamol overdose added some strain onto his already weak heart

(1) The deceased resided at Oak Priory and was the tenant of a privately rented flat in a scheme from a housing provider. He was on a care package provided by Comfort Call under a contract from Stoke on Trent Council. He received visit four times per day principally to administer medication. The medicine was kept in a locked kitchen cupboard in his flat. He had been identified as not being able to manage his own medication. The tenant was easily able to pull open the cupboard door and the barrel of the lock fell out. He overdosed on medication. There appears to be no system of safe storage in place where a resident has been identified as being in need of supervision with medication.
(2)The apparent investigation into the incident was perfunctory and carried out by an untrained member of staff.