Jean Dorothy Gillespie · Prevention of Future Deaths report

On 15 May 2015 I opened an investigation into the death of Jean Dorothy Gillespie aged 89 years. The inquest concluded on 28th October 2015.

The conclusion of the Coroner as to the death was a Narrative verdict:
Jean Gillespie died of bronchopneumonia, the onset of which was contributed to by the effects of not receiving prescribed medication she required to control the potentially life threatening condition Myasthenia gravis.

The medical cause of death was:

1 (a) Acute cardiorespiratory failure
1 (b) Bronchopneumonia
1 (c) Myasthenia gravis

2 Senile Multi Organ Involution.

Residing at a care home for respite care since 9th April 2015 the last of a supply of Jean Gillespie’s prescribed medication Pyridostigmine was administered to her on the morning of 25th April 2015. At approximately 5pm on 26 April 2015 she was observed to be suffering from symptoms attributable to the condition Myasthenia gravis. She was taken to hospital but her condition deteriorated and she passed away at 22.26 hours on 8 May 2015.

1. The inquest heard that a senior member of the care staff with responsibility for administering medication to residents and for re-ordering supplies of medication did not know that the deceased suffered from myasthenia gravis, nor was this a condition she had heard of before.
2. When supplies of the necessary medication were about to expire she did seek to re-order supplies. When they did not materialise she did not appreciate the urgency the situation demanded until symptoms became evident.
3. I am concerned that irrespective of whether this is a care home rather than a nursing home that staff with responsibility for administering and / or re-ordering supplies of medication for potentially life threatening conditions are aware of the conditions and what the medication is prescribed for so that staff can then react accordingly.
4. Further, consideration of the care home records made no reference to the name of the condition, the symptoms that can materialise, nor what the prescribed medication was for. A member of staff previously unfamiliar with this patient who may have responsibility for administering her medication would not have been able to familiarise themselves with the necessary knowledge from a perusal of the care home records and I am concerned there is a risk of future deaths were this situation to be replicated.

At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.