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Calls for better carer training after death of Bucks grandmother

Her son is calling for changes after she passed away last year.

Published by Scarlett Bawden-Gaul at 2:29pm 2nd March 2020. (Updated at 3:34pm 2nd March 2020) 4-minute read.

Calls for better carer training after death of Bucks grandmother

A Buckinghamshire man is urging carers get better training after the death of his mother.

Heather Planner, 87, suffered a stroke after being given the wrong medication by her Carewatch team, who provide home care services in Aylesbury, High Wycombe and Wendover. 

Last year Westongrove Pharmacy gave Heather's carer the wrong prescription, after accidentally putting her paracetamol into another mans paper bag. 

Despite having a mans name on the tablet book and being different to her usual prescription she was given them four times a day over the next two and a half days.

The three carers also signed off to say they had given Heather the medication she needed.

Her son, Jonathan found her slumped at her home and looking at the medication packet immediately realised they were not the right ones. 

Now, Jonathan wants carers and companies to rethink their training:

"It's the most important part of your day, you're giving people medication that could kill them. You've got to be really sure you're doing the right thing at the right time. 

"Ultimately though, it isn't the individual carers responsibility its the person that trained them and the company's to make sure they're operating properly."

After being taken to Wycombe hospital Heather died on April 1st, having suffered a stroke because she had not been taken her prescribed medication.

An inquest was held into the death, which has found there was no procedure in place to ensure individual carers read and specifically acknowledged any medication changes.

It also found that since the death of Heather, this doesn't seem to have changed.

Buckinghamshire's Senior Coronor Cripsin Butler has said:

 "It is unclear what additional measures or cross-checking have been introduced to prevent a subsequent carer from inheriting a medication error and repeating that error.

"There does not appear to be any process for individual carers to sign to acknowledge having read and implemented a patient's care plan in the patient's log book.

"There does not appear to be a system for recording on a patient's records specific medication instructions or changes to medication which might have been given or taken by mobile phone.

"There does not appear to be a system for recording on a patient's records specific medication history, the records at the patient's home being only paper records."

"There is a specific concern in Mrs Planner's case about the robustness of the subsequent Carewatch investigation and any learning that would arise to prevent incidents in the future."

Carewatch gave us this statement:

"On behalf of Carewatch (Mid Bucks), we would like to reiterate and express our deepest condolences to Mrs Planner's son and all of her family and friends.

"Carewatch (Mid Bucks) was an Interested Person at the inquest into Mrs Planner's death and we participated fully, answering all of the questions put to us by the Coroner and her family.

"The Care Quality Commission (CQC) carried out an investigation into this incident prior to the publication of their latest inspection report on our service in November 2019, when we were rated as 'good'. In their report they acknowledged that we had reviewed the way that we support people with medicines; they also acknowledged that "all staff had received additional training to refresh their skills" and that we had carried out our own internal investigation to "ensure the risk of a similar incident was minimized".

"We have responded formally to the concerns raised by the Coroner during the inquest and to the CQC and we will act promptly on any further instruction or guidance we may receive.

"In the meantime, as the inquest has only just concluded, it would not be appropriate to comment further at this time."

Jonathan is aware that a change in procedure cannot change the past, but hopes something good can come from the tragedy:

"Time is a great healer. I am very cross inside and upset that my family have lost my mother...

"I've got to the point that I think the only way that I can feel any kind of relief out of this is to prevent it happening to someone else."

Westongrove pharmacy have been asked for a comment.

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