A practice in the Ashfield area

4. Mrs P complains that a Nottinghamshire care home (the care home) did not administer her mother, Mrs O’s, heart medication (digoxin) on 7 January 2023, or any of her mother’s medication on 8 January 2023.

5. Mrs P says as a result her mother’s health deteriorated and she was admitted to hospital on 8 January 2023 and died on 26 February 2023. Mrs P says what happened has had a huge emotional impact on her, she has lost sleep, feels depressed and she is still grieving her mother’s passing.

6. Mrs P would like the care home to acknowledge any failings, apologise, and improve its services.

7. What follows is a summary of events from the complainant and the Home’s records. We have not included all the details as those involved are already aware of the information. However, we have included this background to put the complaint in context.

8. Mrs O had a medical history of history of chronic kidney disease (CKD - where the kidneys do not work as well as they should), ischaemic heart disease (where the heart’s blood supply is blocked or interrupted by a build up of fatty substances in the heart’s arteries), atrial fibrillation (AF - where the heart rate is unsteady) and anxiety.

9. On 24 December 2022 Mrs O was admitted to the care home for rehabilitation, following discharge from hospital for broken shoulder.

10. She was readmitted to hospital on 8 January 2023 and sadly died on 26 February.

14. Mrs P complains the Home staff failed to administer her mother’s heart medication, digoxin, on 7 January 2023, or any of her mother’s, Mrs O’s, ‘vital’ medication on 8 January.

15. The Home says the digoxin was not administered on several occasions during Mrs O’s stay, as her pulse level was below the level recommended. It confirms on 7 January 2023 she was not given the medication as her pulse was 59 beats per minute (bpm).

16. The NHS website sets out digoxin is a type of medicine that is ‘used to control some heart problems, such as irregular heartbeats. It can also help to manage the symptoms of heart failure, usually with other medicines. It's normally recommended when these other medicines have not been enough to control symptoms on their own. It works by slowing down the heart rate and making the heartbeat more strongly, which makes it easier for the heart to pump blood around the body.’

17. Mrs O’s care records document the digoxin was not administered on 8 January 2023, as she was deeply asleep and difficult to rouse.

18. Care homes in England must act in accordance with the Health and Social Care Act 2008 (regulated activities) Regulations. Regulation 12 ‘safe care and treatment’ states, ‘Medicines must be administered accurately, in accordance with any prescriber instructions and at suitable times to make sure that people who use the service are not placed at risk’.

19. The Home’s medication policy is written in line with national guidance and states it ‘work closely with our GP’s or other visiting medical professionals to ensure that all medication instructions are clear’.

20. The medications Mrs O was prescribed were:

• digoxin – 62.5mg once a day • oxycodone – 10mg, every 12 hours, for severe pain • oxycodone – 5mg/5ml, 2.5ml four times a day and a further 2.5ml four times a day as required • nicorandil 10mg, twice a day • codeine – 30mg four times a day, as required • famotidine - 20mg once a day • febuxostat – 80mg every 72hours • furosemide – 20mg every morning • paracetamol – 500mg, two tablets, four times a day • senna – 7.5mg, once at night • sodium bicarbonate – 500mg, once a day • zopiclone – 7.5mg, half a tablet when needed to aid sleep • bisoprolol – 7.5mg, once a day • atorvastin – 20mg, once at night • mineral eyedrops – 1 drop in left eye, as required

21. Mrs O’s care records document staff raised concern about her health with the GP on 6 January 2023.

22. Mrs O’s care records document on the 7 and 8 January she was given all medications prescribed for her, except digoxin on the 7 January. The records clearly show when they were administered and if not, the reason why.

23. NHS website information about digoxin advises it can take several weeks for digoxin to start to work. Our adviser informs us this is because it needs time to accumulate in the body. The information also states, it will take about eight days for digoxin to be completely out of the body once it a person stops taking it.

24. Our adviser confirms the records indicate the only admission of medication was the digoxin on 7 January 2023. They told us the omission would not have affected Mrs O’s health or her subsequent deterioration and death.

25. We understand how devastating it is to experience the death of a parent and have questions about the care they received. It is our provisional view the staff’s administration of Mrs O’s medications, including her digoxin, was in line with the Home’s medication policy, and the UK government’s Health and Social Care Act 2008 (regulated activities) Regulations 2014.

26. This is because staff have clearly checked her pulse before administration and, in accordance with NHS website information about digoxin, as her pulse rate was too low, did not administer the medication. There is no evidence of more than one day where the medication was not administered to Mrs O. We have also seen the Home appropriately raised concerns about Mrs O’s health with the GP on 6 January 2023.

27. This ends our report.

1. Mrs P complains about the care a Nottinghamshire care home provided her mother. We are sorry to hear of the events that led to Mrs P’s concerns. We understand this has been upsetting and frustrating for her. We recognise the death of her mother continues to affect her.

2. We have seen the administration of Mrs O’s medications was in line with guidance.

3. We do not uphold the complaint.