The coroner says action must be taken after the death of the nursing home !
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A member of Coroner’s team said action should be taken to prevent future deaths after a woman was found to have an “excessive concentration” of the drugs in her system after she died in a nursing home.
An inquest found that Beryl Ellison, who was “in failing health and receiving end-of-life care” at the Alexandra Care Home, in Newton-le-Willows, had died “as a result of her underlying poor health as well as the taking of an excessive amount of her prescribed medication”.
Mrs. Ellison had previously suffered from pneumonia and blood poisoning, and had her leg and finger amputated due to blood clots.
On June 28, 2022, at about 10 a.m., she was due her medication, and a caregiver went to her room, because it was “unusual” that Ms. Ellison hadn’t pressed the call button to get her medication before then. the time. Mrs. Ellison was found to be “extremely drowsy and asleep”.
The care assistant took her notes, which were “alarming” and informed the staff nurse before an ambulance was called.
However, when the care assistant returns to the office to take her call, the nurse informs her that Mrs. Ellison has indeed passed away.
The police and Mrs Ellison’s doctor were called to the house in Wargrave Road, Newton-le-Willows, and she was pronounced dead at 1.52pm.
Action must be taken
The Regulation 28 Prevention ofuture Deaths report, following the conclusion of the inquest into Ms Ellison’s death in December, was sent to the carerour Seasons Healthcare by the Assistant Coroner of St Helens, Knowsley and Sefton, Joanna Thompson.
It is issued when the coroner believes action must be taken by an organization to prevent further deaths.
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The report stated that about four to six weeks before her death, “Ms. Ellison’s son stated that he had raised a concern to the care home about medication being left in his mother’s room, where she was seen to hide it under the bed covers.”
She added that Ms Ellison’s son had been “informed that staff would administer the morphine and would monitor her from then on”.
The report noted that “Ms Ellison’s son was concerned that there had been no change in the practice of care homes since his previous complaint, which could have resulted in his mother taking an accidental overdose of her medication.”
In the report, the assistant coroner added that Mr Ellison’s family “expressed concern that she had been left with a medical syringe unattended by staff and raised concerns about this with the nursing home historically and four days before her death”.
Mrs. Ellison was found to have an “excessive concentration” of the drug in her system “which likely exceeds any acquired tolerance level”.
It was said that “the evidence heard at the inquest revealed no explanation” as to why there was an excessive amount of medication in Mrs. Ellison’s system.
In the report, the coroner concluded: “In my opinion action should be taken to prevent future deaths and I believe you (and/or your organization) have the power to take such action.”
We collect all the necessary information
A spokesperson for the Care Quality Commission (CQC) said: “The CQC is aware of the sad death of a person living at Alexandra Care Home in Newton-le-Willows, and our condolences are with the family.
“We are collecting all necessary information regarding the death to determine our next steps in line with our regulatory authorities.
“CQC’s priority, at all times, is the health and well-being of people who use health and social care services, and all information we receive informs our monitoring of services and future inspections.”
The Star has contacted the providerour Seasons Healthcare for comment.
Aour Seasons spokesperson previously told the media, “The safety and well-being of our residents will always be our top priority.
“We are currently working transparently with the relevant authorities regarding the death of Ms. Beryl Ellison.
“Our thoughts are with the family at this sad time.”