Serious and repeated failures in the management of medicines resulted in the Care Quality Commission (CQC) bringing a prosecution against a Shropshire Care Home after the death of resident Dennis Wootton in April 2015.

Shortly before his death, Mr Wootton had been discharged from hospital where he had been prescribed an ongoing course of anti-coagulant medication by doctors, back to his care home. On his return to the Coton Hill Care Home in Shrewsbury, significant errors with the ordering and administration of this medication meant that Mr Wootton did not receive anti-coagulants for up to 30 days before he died.

His death was referred to the coroner as a result of the medicine management failures being identified. A post-mortem revealed the cause of death as pulmonary thromboembolism and deep vein thrombosis.

care home

Prosecution of the Case

The case against the care home was heard at Telford Magistrates Court in September 2016. The Court was told that on reviewing Mr Wootton’s medication records, inspectors had discovered inaccuracies with recording the dosage and length of time that the anti-coagulants should have been taken. The care home failed to re-order the medication once Mr Wootton’s supply had run out which resulted in him not having access to the drug in the weeks before his death.

Both the private company that owned the care home and the former manager pleaded guilty to failing to provide safe care and treatment resulting in a significant risk of exposure to avoidable harm, a criminal offence under Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During sentencing, District Judge Nigel Cadbury stated there had been “significant failures” by the owners and former manager of Coton Hill House. Although it could not be established that Mr Wootton’s death was directly caused by his not taking the anti-coagulant medication, the judge ruled that the errors identified resulted in Mr Wootton being exposed to ”significant risk which could have been fatal.

The owners and former manager were fined £50,000 plus a £120 victim surcharge and £665 plus a £66 victim surcharge respectively.

CQC Comments

During inspection, the care home’s medication management and recording systems were found to have put residents at risk of significant harm. Crucial medications to treat various serious medical conditions had repeatedly been allowed to go out of stock, medicines went missing and the inadequate recording of medications’ administration and strength created the risk of overdose.

In a statement, Deb Holland, Head of Adult Social Care Inspection for CQC in the Central region, said:

We appreciate how distressing this has been for Mr Wootton’s family and, like them, hope this case prompts other care home operators and managers to review their medicine management systems to better ensure people’s safety.” She added, “If we find that a care provider has put people in its care at serious risk of harm, we will consider holding them to account using our powers to prosecute.

A spokesman for the owners of Coton Hill House said the company “made efforts to ensure the failings are not repeated in future.

You can read the full report here.

Georgina Parkin a solicitor at Truth Legal specialising in care home compensation claims on behalf of victims and their families (though not involved in this particular case) said:

This is another shocking example of inadequate care being provided in a care home. The failings at this particular care home were really quite basic things.”

“We at Truth Legal are compiling this information as a resource for other families who have had issues with other care homes, as it appears to us that standards in care homes are declining.”

While a criminal prosecution punishes the care home management for their failings, this may be of little comfort to you if you or a loved one has suffered as the result of neglect. Compensation can never make up for such treatment, but it may ease financial difficulties that arise from it. Truth Legal are specialists in this area of law, and we represent injured people throughout the country. If you have been injured in a care home, or if you are the relative of someone who has suffered injury in a care home, and you want a confidential, no-obligation consultation, please get in touch with one of our specialist solicitors today.

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Catherine Reynolds
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