Betty Addison

During the inquest evidence was heard that: As a result of the surgical treatment Mrs Addison received at the Royal Albert Edward Infirmary, Wigan on the 15th October 2015, she was given prophylactic treatment in line with hospital policy in order to reduce the risks of a deep vein thrombosis occurring following the surgery. As part of this treatment Mrs Addison was prescribed Dalteparin which is a low molecular weight heparin administered by injection. This medication was started on the October 2015 and she was prescribed sufficient medication upon her discharge for the injections to continue until the November 2015. From the records relating to Mrs Addison's care at the Alexandra Court Care Home; Addison continued to be given Dalteparin injections until the 22nd November 2015. She therefore received an additional 5 injections than was prescribed to her, Addison left the Royal Albert Edward Infirmary with 24 injections and from the evidence given at the Inquest it was not known where the additional 5 injections had come from, or why were given to Mrs Addison: It was confirmed at the Inquest that these injections had been incorrectly given to Addison. From the evidence at the Inquest it was clear that this additional medication was not causative or contributory to Addison's death, however she was given medication that she should not have been: I have concerns with regard to the following: The administering of medications at Alexandra Court Care Home is not sufficiently controlled and other residents at the Home may be given medication other than in accordance with that prescribed, whether that is an excessive amount; Or a reduced amount; as the 5 injections given to Mrs Addison must have come from somewhere and potentially another resident's supply. I therefore request that a review be conducted by Cuerden Care Homes of the policies and procedures adopted by Alexandra Court Care Home in relation to the administering and monitoring of medication in order to ensure the correct mediation is given to residents as administering incorrect mediation can lead to death; 14th 17th Mrs Mrs they Mrs Mrs

ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and believe you and/or your organisation have the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report; 21s April 2016. I, the coroner, may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed; COPIES and PUBLICATION I have sent copy of my report to the Chief Coroner and to the following Interested Persons: Mrs Addison's Daughter on behalf of the family I have also sent this report to the Wigan Borough Clinical Commissioning Wigan Life Centre, College Avenue; Wigan, WNI 1NJ who may find it useful or of interest. I am also under a to send the Chief Coroner a copY of your response: The Chief Coroner may publish either or both in complete or redacted Or summary form: He send copy of this report to any person who he believes may find it useful or of interest; You make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner: Dated Signed PbbA} 25th February 2016 Rachael C Griffin days Group, duty may may