Care home death after medication withdrawn

Wednesday 18 February 2015

An elderly and frail man suffering from dementia died in a care home after the medication he was being given without his knowledge was suspended for 24 hours.

The man – identified only as Mr H in a report – was being treated for pneumonia, but when a social worker saw that he was being treated without his consent or knowledge, he told the care home they were probably breaking the law, and they stopped putting the antibiotics in his food.

Mr H’s family say they are happy with the care he received, and Health have pointed out that giving dementia patients medication “covertly” is not hugely unusual. But they say no notes had been made on the patient’s file by his GP that a decision had been reached to give him the medicine without his consent.

A meeting was held without Mr H’s GP – because he was seen as “having done something wrong” – about the patient’s care, and the medication was restarted after 24 hours. But five days after that, Mr H died, and Health say that they don’t know whether the gap in the antibiotic treatment contributed to his death.

The death, which happened in 2013, led to a Serious Case Review, which happens when an independent expert examines an unusual case to see if there were mistakes made and whether changes need to be made.

The review found the case was made more complicated by the fact that Mr H was, in the words of professionals “a challenging man”, who had decided when he went into a care home that he didn’t want to speak anymore. Mr H had never had a doctor until right at the end of his life, but was very ill and suffering from dementia – the GP who had been treating him had reviewed his notes and decided that he had to take some medical decisions on his behalf.

Health say that they have changed their policies so that it would be “highly unlikely” that the same events could be repeated – and they say that a new mental health capacity law is on its way which will add more clarity.

The Serious Case Review into Mr H’s death says that there should be a “refresh” of adult safeguarding processes, that homes should seek clarification from GPs on treatment questions, and that patients who need complex support should be allocated a “care manager” to oversee their treatment.