Beatrice Wright Herriot Gatt · Prevention of Future Deaths report

On 30th July 2012 I commenced an investigation into the death of Beatrice Wright Herriot Gatt aged 69 years. The investigation concluded at the end of the inquest on 3rd September 2014. The conclusion of the inquest was:

Beatrice Wright Herriot Gatt was a patient at Shire Lodge Nursing Home. Due to an error her anti-psychotic clozapine medication was not given on 6th, 7th and 8th May 2012.

Subsequently her mental state deteriorated and she was transferred to the Welland psychiatric unit. There she suffered two falls, fractured her hip and was conveyed to Kettering General Hospital for surgery.

She later returned to the Welland Centre where she was found on 18th July on the floor. She was confirmed deceased at Kettering General Hospital later that day. The cause of her death was:-

1 a) Gastrointestinal haemorrhage
b) Duodenal ulcer

It cannot be confirmed that there was a causal connection between the cessation of clozapine, her falls (fracture) and subsequent death.

On the 18th July 2012 the deceased was discovered unresponsive at her home address. She was taken to Kettering General Hospital but treatment was unsuccessful and her death was confirmed at 06.46 hours.

1) Mrs Gatt was not given her anti-psychotic clozapine medication due to an error in the medication not being transferred from 1 Mars sheet to another. There did not appear to be any formal training of nursing staff as to how the Mars sheet