Ian Hall · Prevention of Future Deaths report

On 17th November 2020 I commenced an investigation into the death of Ian Hall. The investigation concluded on the 3rd June 2021 and the conclusion was one of Narrative: Died from aspiration pneumonia following a choking incident after admission following a fall in combination with Covid-19 pneumonitis. The medical cause of death was 1a Aspiration pneumonia on a background of a choking incident, Covid-19 pneumonitis; II Alzheimer's dementia

Ian Hall had Alzheimer's and was vulnerable. He had carers in the community. He was admitted to Stepping Hill Hospital on 27th October following a fall. No injuries resulted from the fall. On 28th October during a post admission medicines reconciliation check at Stepping Hill Hospital it was identified that in the community he had been dispensed by the community pharmacy Amitriptyline rather than Atenolol which was on his prescription. Amitriptyline would have led to increased drowsiness and an increased falls risk. On 28th October he choked on medication. He subsequently developed aspiration pneumonia and was treated but continued to deteriorate. On 2nd November a Covid-19 swab was positive. He was treated for Covid-19 but deteriorated further. On 14th November 2020 he died in Stepping Hill Hospital from a combination of aspiration pneumonia and Covid-19 pneumonitis.

1. It was unclear how Amitriptyline rather than Atenolol had been dispensed in the community.

2. It was unclear what checks the pharmacy in question had or any pharmacy has to avoid the inadvertent dispensing to a vulnerable adult where the carers role is to administer whatever medications are collected from the pharmacy in the name of the individual. The inquest was told that the carers in this situation generally will have no clinical training. Therefore, their role is to check the medication is in an individual’s name and give it to the individual in compliance with what is on the label. It is not part of their role to cross check previous medications or query changes to medication.