Concern over medicine discrepancies after accidental death


Poor record-keeping and medicine discrepancies were two issues raised by the coroner after investigating the ‘accidental death’ of care home resident Mr Mildred Horrex.


On 30th December 2017 Mrs Mildred Horrex, who was left sleeping in a chair in her room at Pelham House, suffered an unwitnessed fall in which she suffered a fracture to a number of bones in her neck. She was taken to hospital but sadly did not recover from her injuries and she died on 18th January 2018.


On 22nd January 2018, the coroner began an investigation into the death of Mrs Horrex. The inquest concluded that Mrs Horrex died an ‘accidental death’.


During the course of the inquest, the evidence revealed matters giving rise to concern. In the opinion of the coroner, there was a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you.


The coroner raised two issues of concern:


  • During the course of the Inquest, it was clear that overall the record-keeping in respect of Mildred was poor. The investigation found that there was insufficient information taken about Mildred by the home before her admission to Pelham House, the information that was taken was at times inaccurate and this lead to an inadequate fall risk assessment being insufficient.
  • Whilst the drugs chart showed that Mildred was taking her medication regularly the amount of medication that was found after her death showed that this could not be the case. We were told that monthly drugs audits were apparently carried out but they did not pick up the discrepancies in the recording on the drugs charts and the amount of medication held.


The coroner in the case apologised for the delay in the Inquest process.


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You can read the full coroners report below.


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Elements of this article are being shared under the Open Government Copyright licence.



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