Wigan grandad died after being accidentally given 10 times his medicine dose at care home - but inquest does not link the two events

The care home which accidentally gave David Fitton the overdose has apologised, although the coroner was not able to say whether it led to his death.

The Bolton hearing was told Mr Fitton had dementia and had been prescribed Risperidone for this condition.

He lived at home supported by his wife Jennifer and family. During 2019 he went to the Belong Wigan care village at Platt Bridge for a week of respite care while Jennifer underwent knee surgery.

Three days into his stay, David was administered not 0.25mg his prescribed dose of medication but 2.5mg.

He was taken to hospital by ambulance, assessed and discharged later the same day.

However, he was re-admitted the following day with difficulty swallowing, involuntary spasms and speech problems.

The swallowing difficulties led to a diagnosis of aspiration pneumonia, which happens when food or liquid is breathed into the airways or lungs instead of being swallowed.

David died around 10 weeks later, aged 76. A post-mortem examination report found his cause of death was aspiration pneumonia caused by dysphagia (swallowing problems) of an unknown cause, and it also noted his dementia.

The staff member who had administered the medication received disciplinary action and underwent re-training.

Belong has apologised for the error and promised to review practices.

But in her narrative verdict Coroner Rachel Syed said: “It is not possible to determine that the accidental overdose of Risperidone is implicated in the deceased's death or whether death occurred due to complications of the Risperidone medication itself or due to a cerebral event.”

Following her husband’s death, Jennifer, 72, and daughters Jayne and Louise, 44 and 46, instructed medical negligence experts at Irwin Mitchell to investigate his care under Belong and to support them through the inquest process.

The family are now joining their legal team and the coroner in calling for lessons to be learned and changes made.

Ayse Ince, the specialist medical negligence lawyer representing David’s loved ones, said: “Three years on, David’s family, particularly his wife Jennifer, are still struggling to come to terms with losing him so tragically.

“Following his death, Jennifer, Jayne and Louise expressed concerns over the care provided to him. While the inquest and listening to the circumstances surrounding David’s death have been very painful for the family, they have been determined to understand what happened and to do everything within their control to ensure the same mistakes are not made again.”

Former engineering manager David went to Belong with Jennifer, Louise and Jayne for respite care on June 16, 2019.

The inquest heard Jennifer, who was undergoing surgery the following day, provided carers with a note of David’s medication, including his dosage.

Almost four hours after the overdose had been administered on June 19, David’s daughter Jayne was first informed of the error and an ambulance was called.

Jayne arrived at Belong and David was taken to hospital early that afternoon. Although the family still had concerns about his condition, he was discharged at 5pm and returned to the family home with Jayne, but he continued to deteriorate through the night.

At around 6am on June 20, David was taken back to A&E in a semi-conscious state, unable to walk or talk with involuntary muscle spasms and issues with swallowing.

David didn’t recover from these symptoms. He continued to deteriorate over the following weeks, with various complications, and died on August 30.

Ms Syed voiced several concerns and intends to write three letters to address them; one to the Care Quality Commission (CQC), one to Belong and one to the Medicines and Healthcare Products Regulatory Agency (MHPRA).

She said she would ask the CQC to remind care homes of the impact of appropriate safety checks when administering drugs to residents.

Belong would receive a letter of concern, reminding it of the importance of keeping up-to-date records, as it was confirmed during the evidence heard at the inquest that the care staff failed to do this for David.

And the MHPRA letter would highlight the importance of having syringes with accurate and clear markings and further, the benefit of using a two-person safety netting system when administering drugs.

At the time of his death, David had been married to Jennifer for 45 years and they had two daughters and five grandchildren.

Louise and Jayne have said: “Mum was Dad’s main carer, but we helped out as much as we could. When we took him to Belong, we thought he was in the best place possible. It was a huge shock when we got the phone call to say he had been given an overdose.

“Dad was in hospital for 10 weeks after that, and it was devastating to see him suffer and deteriorate and know there was nothing we could do to help.

“It’s been three years since we lost him, but we feel like time has stood still for us as a family as we had so many concerns and questions over what happened. Mum, in particular, has found the pain and grief unbearable.

“Whilst the inquest has been incredibly difficult as we’ve had to relive everything again, at least we have some answers now.

“We know that nothing will ever bring dad back to us. However, it’s extremely important to us that nobody else is given the wrong dosage of medication and we hope that where appropriate care homes improve their systems and controls.

"In particular we would like to see a two-person checking system introduced – in the same way that hospitals do - as we feel that had this been in place at Belong in June 2019 this would not have happened to dad.

“We also call on them to make sure their staff are given the right training in the hope that it will help prevent other families from going through what we have.

"It’s equally as important to us that such measures and changes will protect staff and carers from being in the terrible position of finding that they have made an error and the consequences of that error.

"We accept that this was a human error and we hope that change will support staff to do their jobs safely in the future.”

Susan Goldsmith, Chief Operating Officer for Belong, commented: “Mr Fitton was a well-liked member of the Belong community and we are deeply saddened at the circumstances surrounding his passing. We continue to offer our thoughts and condolences to Mr Fitton’s family.

“While the coroner noted from the medical evidence that the actions of our team did not cause his passing, this incident was taken extremely seriously in Belong. We immediately reviewed our practices, safeguards and training around the administration of very low dose and complex liquid medications before implementing a number of changes that have been formally cascaded to the wider organisation to prevent a similar incident from happening again.

“On behalf of Belong, I would to like to offer my apologies and condolences to Mr Fitton’s family at this distressing time.”