A coroner was unable to determine whether a man given ten times the correct dose of a dementia drug by a carer died as a result of the incident - despite his family raising concerns.
David Fitton died 10 weeks after overdosing on his medication at Belong care home in Wigan in June 2019. The dad-of-two and grandfather-of-five was receiving respite care at the facility, in Platt Bridge, while his wife and carer Jennifer underwent surgery.
However, three days into his stay, Mr Fitton was taken to hospital after a carer "accidentally" gave him the wrong dose of his medication. He was assessed and discharged but returned to A&E the next day where doctors diagnosed him with aspiration pneumonia, which occurs when food or liquid is breathed into the airways or lungs instead of being swallowed.
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Mr Fitton died about 10 weeks later, aged 76. A post-mortem examination report gave his cause of death as aspiration pneumonia caused by dysphagia (swallowing problems) of an unknown cause.
An inquest into Mr Fitton's death was held at Bolton Coroner's Court last Friday (September 30). Despite his family's concerns, coroner Rachel Syed ruled that "it was not possible to determine" whether the overdose had contributed towards Mr Fitton's death.
Delivering a narrative conclusion, the coroner said Mr Fitton died as a result of "aspiration pneumonia, sepsis and dysphagia of an unknown cause". She also noted his dementia as a contributory factor in his death.
Following the hearing, Mr Fitton's daughters, Louise and Jayne, said: “Mum was dad’s main carer, but we helped out as much as we could. When we took him to Belong, we thought he was in the best place possible.
"It was a huge shock when we got the phone call to say he had been given an overdose. Dad was in hospital for ten weeks after that, and it was devastating to see him suffer and deteriorate and know there was nothing we could do to help.
"It’s been three years since we lost him, but we feel like time has stood still for us as a family as we had so many concerns and questions over what happened. Mum, in particular, has found the pain and grief unbearable.
"Whilst the inquest has been incredibly difficult as we’ve had to relive everything again, at least we have some answers now. We know that nothing will ever bring dad back to us."
Mr Fitton, a former engineering manager, went to Belong for a week of respite care on or around June 17, 2019. He had previously attended the care home two or three times a week to access day services, according to the record of inquest.
Ms Syed ruled that the "accidental overdose", which happened on the morning of June 19, was down to several factors, including "human error" and a lack of marking on the syringe, which caused the carer to "become confused". "The error was quickly recognised and an onsite nurse was summoned," the record of inquest reads.
Care home staff contacted 111 and were advised that Mr Fitton did not require hospital treatment. However, he was later taken to A&E after carers noticed he "looked sleepy and drowsy and had vomited".
Although the family say they still had concerns about his condition, he was discharged that same day. However, he returned to the hospital the next morning, having deteriorated overnight.
Mr Fitton was in a semi-conscious state, unable to walk or talk with involuntary muscle spasms and issues with swallowing, his loved ones claim. His condition continued to worsen over the next ten weeks and he died on August 30.
Susan Goldsmith, chief operating officer for Belong, said: “Mr Fitton was a well-liked member of the Belong community and we are deeply saddened at the circumstances surrounding his passing. We continue to offer our thoughts and condolences to Mr Fitton’s family.
“While the coroner noted from the medical evidence that the actions of our team did not cause his passing, this incident was taken extremely seriously in Belong. We immediately reviewed our practices, safeguards and training around the administration of very low dose and complex liquid medications before implementing a number of changes that have been formally cascaded to the wider organisation to prevent a similar incident from happening again.
“On behalf of Belong, I would to like to offer my apologies and condolences to Mr Fitton’s family at this distressing time.”
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