Betty Addison · Prevention of Future Deaths report

On the 11th December 2015 I commenced an investigation into the death of Betty Addison, born on the 1st December 1925.

The investigation concluded at the end of the Inquest on the 12th February 2016.

The Medical Cause of Death was:

1a Bilateral Pulmonary Embolism
1b Deep Vein Thrombosis
1c Immobility following fracture of right neck of femur (operated on)

The conclusion of the Inquest was that Betty Addison died as a consequence of immobility following the injuries sustained in an accidental fall and the subsequent surgical treatment of those injuries.

On the 14th October 2015 the deceased, who was usually very mobile for her age, fell whilst walking for the bus sustaining a fracture to her right neck of femur. She was taken to the Royal Albert Edward Infirmary, Wigan where the fracture was surgically repaired on the 15th October. She was discharged from hospital to Alexandra Court Care Home, Wigan on the 24th October for rehabilitative care and later transferred to Grange Care Home, Howard Street, Pemberton, Wigan on the 26th November. On the 2nd December she collapsed in her room at Alexandra Grange Care Home and died.

During the inquest evidence was heard that:

1. As a result of the surgical treatment that Mrs Addison received at the Royal Albert Edward Infirmary, Wigan on the 15th October 2015, she was given prophylactic treatment in line with hospital policy in order to reduce the risks of a deep vein thrombosis occurring following the surgery. As part of this treatment Mrs Addison was prescribed Dalteparin which is a low molecular weight heparin administered by injection. This medication was started on the 14th October 2015 and she was prescribed sufficient medication upon her discharge for the injections to continue until the 17th November 2015.

2. From the records relating to Mrs Addison’s care at the Alexandra Court Care Home, Mrs Addison continued to be given Dalteparin injections until the 22nd November 2015. She therefore received an additional 5 injections than was prescribed to her. Mrs Addison left the Royal Albert Edward Infirmary with 24 injections and from the evidence given at the Inquest it was not known where the additional 5 injections had come from, or why they were given to Mrs Addison. It was confirmed at the Inquest that these injections had been incorrectly given to Mrs Addison. From the evidence at the Inquest it was clear that this additional medication was not causative or contributory to Mrs Addison’s death, however she was given medication that she should not have been.

I have concerns with regard to the following:

1. The administering of medications at Alexandra Court Care Home is not sufficiently controlled and other residents at the Home may be given medication other than in accordance with that prescribed, whether that is an excessive amount, or a reduced amount, as the 5 injections given to Mrs Addison must have come from somewhere and potentially another resident’s supply.

2. I therefore request that a review be conducted by Cuerden Care Homes of the policies and procedures adopted by Alexandra Court Care Home in relation to the administering and monitoring of medication in order to ensure the correct medication is given to residents as administering incorrect medication can lead to a death.