A care home resident died after mistakenly being given the wrong medication by an unqualified nurse, an inquest has heard. Fiona Jayne Thorne, 36, passed away after Katherine Hutchinson administered a fatal dose of a powerful anti-psychotic drug.
Ms Hutchinson was the nurse in charge at Whitwell Park Care Home in Whitwell, Derbyshire, on the evening of Ms Thorne's death. The error was made on October 6, 2010, when the resident, who had learning difficulties, was given clozapine intended for someone else, reports DerbyshireLive.
Senior Coroner Dr Robert Hunter said Ms Hutchinson was aware of the mistake but made "gross failures" by not reporting it and seeking medical attention. He found Ms Thorne's death "was contributed to by neglect."
After administering the incorrect medication, Ms Hutchinson took Ms Thorne to bed, leaving her there until she was found by a colleague carrying out routine checks in the middle of the night. She was discovered lying on her bedroom floor in the dark.
When the alarm was raised, Ms Hutchinson arrived at the room "within 30 seconds". She said Ms Thorne had already died and no CPR was carried out nor an ambulance called, contrary to the care home's rules.
Chesterfield Coroner's Court heard in evidence that when a patient is unexpectedly found unconscious and unresponsive, the default position is to begin chest compressions and call the emergency services. Ms Hutchinson's fatal mistake was only discovered when an audit of the medicine trolley revealed a quantity of clozapine was missing.
The inquest also heard that Ms Hutchinson, despite being the nurse in charge that evening, "was not qualified to verify death" but "took it upon herself and stated that Ms Thorne had died or was dead".
Dr Hunter told the court that Whitwell Park "did not of itself initiate any meaningful investigation into the circumstances of Ms Thorne's death" nor suspend Ms Hutchinson from duty. Ann Gibbons, a director at the care home, told the hearing that a suspension was discussed but she could not give a reason as to why it did not happen.
It meant that Ms Hutchinson continued to work and was left in charge of residents following Ms Thorne's death – something that "continued to place other residents at risk of harm and danger", the inquest found. In his summary, Dr Hunter said: "Either the directors and management of Whitwell Park failed to appreciate the significance of the circumstances in which Ms Thorne came by her death or they chose to bury their heads in the sand, rather than being proactive in investigating and taking appropriate action in relation to Katherine Hutchinson."
The coroner also questioned witnesses, including Ms Hutchinson, about the nature of her training and recruitment. She started working at the care home in September 2009 but her induction was not marked off on her personal file until the following May.
Dr Hunter said: "We heard that Katherine Hutchinson alleged to have a degree in nursing from Sheffield University. My investigations both at Sheffield University and Sheffield Hallam University found no record of Katherine Hutchinson ever attending a nursing course there or for that matter graduating with any degree or diploma."
Mary Marsh, the registered manager of Whitwell Park, said she had assessed Ms Hutchinson twice in the administration of medications but no paperwork demonstrating she had been signed off as competent was submitted to the court. Medication training from Lloyds Pharmacy was shown to have been completed only after Ms Thorne's death.
Angela Starr, an inspector for the Care Quality Commission watchdog, made an unannounced inspection of Whitwell Park in February 2011 and found the training records for staff were very poor. In particular, Ms Hutchinson's training records were poor.
Concluding the inquest, Dr Hunter delivered a narrative verdict, stating that Ms Thorne died as a result of the toxic effects of a "high dose of clozapine, administered by her healthcare professional. The clozapine was not prescribed for Ms Thorne but for another patient."
Dr Hunter continued: "On the balance of probabilities, the healthcare professional was aware of the error and failed to report it or take any action to seek medical attention for Ms Thorne. The failures to acknowledge the drug maladministration and to seek medical attention were gross failures and as such Ms Thorne’s death was contributed to by neglect."
DerbyshireLive has contacted Whitwell Park Care Home for its response to the inquest's findings.
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