Date of prep: December 2020
Prescribing information and
adverse events reporting
For healthcare professionals only
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:
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.
Elements of this article are being shared under the Open Government Copyright licence.
Pharmacy in Practice is a UK pharmacy publication with its roots in Scotland.