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Heartbroken son calls for change in law after mum died when she was given prescription medication for a man
A son is calling for a change to the law after his mum died when she was given prescription medication - for a man.
Heather Planner, 87, was given the wrong medication by carers from Carewatch Mid Bucks who visited her at home four times a day, an inquest heard.
They had gone to collect replacement medication after an error, but the medical professionals failed to notice they had collected the wrong type.
As a result - for four times a day over three days - the carers gave Heather medication designed for a man - causing her to have a stroke at her home.
Senior coroner Crispin Butler heard three staff from Carewatch Mid Bucks had failed to spot tablets handed over by the pharmacy were for a male patient.
Mr Butler said in a hearing in Beaconsfield on Thursday that action should be taken to prevent similar deaths.
And speaking after the coroner's ruling, Heather's son Jonathan Planner, 56, said care providers must be more vigilant in the future.
He said: "I cannot understand how a 'trained' care team can administer someone else's medication four times a day over three days.
"The dossett box clearly had a man's name on it five times.
"All the medication looked different to the day before, different colours, different shapes and different amounts, yet nobody questioned this."
Heather was being cared for by carers from Carewatch Mid Bucks, who provide home care services in Aylesbury, High Wycombe and Wendover.
She suffered the fatal stroke at her home in Ellesborough, Bucks, in April last year.
A post-mortem found that it was not the wrong tablets that led to her stroke, but the lack of her correct medication that caused it.
Jonathan added: "It could save a life if people are made aware to not always simply trust that the medication they have been given is the correct medication.
"If a local care firm has failed to do this properly others could be as well and people need to be made aware.
"We see hundreds of these types of cases each year but there's never any learning, we just see another one a few months later, I am determined to try to make enough noise that real learning is done here and we don't see a repeat.
"My motivation here is to try to firstly stop this from happening again, and alert people as to the dangers of simply assuming that you can trust the medication given to you by professionals.
"You should always read labels and always ask others around helping you to do the same, it could save your life."
The original inquest was held in November last year and this week's hearing saw the coroner present a Prevention of Future Deaths report.
In the report he said he was told at the inquest that the mother of one suffered a fatal stroke because she did not receive her proper apixaban anticoagulation medication.
Mr Butler said he would send the family's concerns to the chief coroner and the Care Quality Commission.
He said there was no procedure in place to ensure individual carers read and specifically acknowledged any medication changes.
The coroner added: "There is a specific concern in Mrs Planner's case about the robustness of the subsequent Carewatch investigation and any learning that would arise to prevent incidents in the future."
The CQC's Head of Inspection (South Central), Rebecca Bauers said: "CQC can confirm we are aware of the death of Mrs Planner and we offer our condolences to her family at this time.
"We are aware of the inquest and we now have a copy of the coroner's report. We will review this report and consider what regulatory action CQC may take. Until then it would be inappropriate to comment further."
Mr Planner has also raised his concerns with Bucks County Council's safeguarding team and is taking legal action against Carewatch Mid Bucks.
After the hearing Carewatch Mid Bucks said the company wanted to "reiterate and express our deepest condolences to Mrs Planner's son and all of her family and friends".
A spokesperson said: "Carewatch (Mid Bucks) was an Interested Person at the inquest into Mrs Planner's death and we participated fully, answering all of the questions put to us by the coroner and her family.
"The Care Quality Commission (CQC) carried out an investigation into this incident prior to the publication of their latest inspection report on our service in November 2019, when we were rated as 'good'.
"In their report they acknowledged that we had reviewed the way that we support people with medicines; they also acknowledged that 'all staff had received additional training to refresh their skills' and that we had carried out our own internal investigation to 'ensure the risk of a similar incident was minimised'.
"Given that we are now in the process of addressing certain concerns raised by the coroner, it would not be appropriate to comment further at this time."
A county council spokesman said: "We understand how distressing this situation has been for Mrs Planner's family and offer our sincere sympathies.
"Any safeguarding concerns that are raised with us are always taken extremely seriously.
"We have procedures in place to ensure such concerns are investigated so that appropriate actions are taken."
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Last updated by System Admin on 27th August, 2018