"It is abundantly clear that some very simple safeguards for this vulnerable, elderly and dependent patient were not in place and that processes should be tightened up."
A senior coroner has issued a Prevention of Future Death notice in the case of a Buckinghamshire woman who died after being given the wrong medication by three different caregivers.
Heather Planner, 87, was being cared for by Carewatch Mid Bucks when she was given medication, dispensed from a pharmacy, meant for a male patient.
Mrs Planner suffered a fatal stroke because of the mix-up which meant she was given the wrong medication four times a day for two and a half days, and which prevented her from receiving her proper apixaban anticoagulation medication. Mrs Planner died at Wycombe Hospital on 1 April 2019.
Senior coroner Crispin Butler held a hearing in Beaconsfield yesterday, following an inquest in November, and said action should be taken to prevent similar deaths.
Specialist clinical negligence lawyer Marguarita Tyne from national law firm Clarke Willmott LLP, was instructed by Mrs Planner’s son Jonathan Planner to assist with the case.
Ms Tyne said: “We are pleased that the coroner took this matter so seriously and issued a Prevention of Future Death notice to the involved parties – the Westongrove pharmacy which made the dispensing error and Carewatch, which provides home care services.
“Following the inquest in November a series of questions were raised over the two separate organisations. It is abundantly clear that some very simple safeguards for this vulnerable, elderly and dependent patient were not in place and that processes should be tightened up.”
Jonathan Planner said: “For my mum it is unfortunately too late but I want to raise awareness of this so that it doesn’t happen to another family.
“The fact that mum was let down by two separate organisations and by three carers within one organisation is deeply concerning.
“There are easy solutions to prevent this from happening again and I’m determined to ensure that processes are changed. Rigorous training and robust systems are needed to protect the elderly and vulnerable people most at risk.”
As well as assisting Mr Planner with preparations for the inquest, Ms Tyne is now dealing with a civil claim and both defendants have been notified.
She said: “We are delighted that the coroner will now send his concerns to the chief coroner and Care Quality Commission.
“Lessons can and should be learned from this tragedy so that it doesn’t happen again.”
Marguarita Tyne is a partner in the clinical negligence team at Clarke Willmott LLP. Specialising in brain injury, delayed stroke diagnosis and catastrophic injury, Marguarita is also experienced in supporting clients at inquests.
Clarke Willmott is a national law firm with offices in Birmingham, Bristol, Cardiff, London, Manchester, Southampton and Taunton.
For more information visit www.clarkewillmott.com