Frank was a resident at a care home in his local community. He suffered from dementia and was taking various types of medication, including alendronic acid for osteoperosis; a health condition that weakens bones, making them fragile and more likely to break. Alendronic acid must be taken in a very specific manner – they must be ingested whole with a large amount of water, and the patient must remain upright for 30 minutes after administration. Shortly after Frank’s admission, his GP visited the care home due to concerns about him chewing his tablets.
Frank was given the wrong medication in a care home
The GP took a list of his prescribed medications back to the surgery to determine what could be changed to liquids. At that stage she noted that she felt alendronic acid was no longer necessary and discontinued it. There was some dispute as to what happened next. The GP called the care home and spoke with the nurse. The nurse alleged the GP did not tell her to stop alendronic acid but the GP said she did. The medications were then delivered by a pharmacy over with MAR sheets, which are used to record all medication that is administered to patients. The sheets did not include alendronic acid. For an unknown reason, the medication packets were then placed in a cupboard and never registered in, so all medication continued in tablet form.
Soon Frank developed sores in his mouth and saw a GP, who prescribed medication for thrush. He was then noted to be struggling to eat and drink. Despite this, the staff continued to administer his medication in tablet form, including alendronic acid.
The next day, Frank was visited by a doctor who noted that he was struggling to breathe and had a fever, and his mouth was noted to be crusted and black inside. As a result, he was admitted to hospital and treated for pneumonia. Unfortunately, Frank passed away shortly after his arrival.
The doctor who had referred Frank to the hospital raised a safeguarding concern about the continued use of tablet medication, and an inquest was planned. A post mortem report indicated that he was suffering from aspiration pneumonia and the likely cause of this was from the severe ulceration. There was no evidence of Stevens Johnson syndrome; a rare, serious disorder of the skin and mucous membranes that is usually caused by a reaction to a medication or an infection, so it was concluded that the ulceration was probably caused by the continued administration and chewing of tablet medication.
The nurse alleged that the doctor had failed to communicate to the care home that the alendronic acid should be stopped. However, she admitted that the liquid medication had not been registered in correctly because she had wanted to finish her shift and subsequently left them in a cupboard. She tried to argue that this was acceptable as the medication was only meant to start the following month, but it was clear from the records this was not the case. As a result, the unopened parcels of medication remained in the cupboard until the doctor raised concerns shortly before Frank passed away. The nurse admitted that if the medication had been correctly registered into the care home, they would have called the GP to check on the prescription, and at that stage the GP would have confirmed that alendronic acid should have been stopped.
Compensation for wrong medication being given in a care home
An offer of £25,000 was accepted by Frank’s widow, which was able to assist in covering bereavement and funeral expenses.
Full value of the claim was £24,860.50 including a small amount of general damages (max £5000)