Care home resident died after medication overdose

A care home resident was given an overdose of medication which contributed to his death, an inquest has heard.

Former chip shop owner John Collinson - known as Ricky - from Llanfairfechan in Conwy county died in August 2022, eight weeks after he was given 10 times more than his correct dose of medication over four days.

The 88-year-old lived at Kinmel Lodge in Kinmel Bay at the time, and had been mobile and physically active before the error was made, but afterwards became mostly confined to his bed, the hearing in Ruthin, Denbighshire, was told on Monday.

A coroner concluded the medication error "more than minimally" contributed to his death.

Mr Collinson died from bilateral pulmonary emboli - a blockage of the lungs - as a result of a deep vein thrombosis, a type of blood clot, the inquest was told.

His son, Kevin Collinson, described how the father-of-five had lived at Kinmel Lodge for about two years after developing dementia, and had been started on a low dose the drug risperidone in January 2022, to help calm his outbursts of agitation.

He added his dad had been physically mobile, even dancing at Elizabeth II's jubilee celebration just a few weeks before he suddenly became "wiped out" and confined to his bed, and he knew something was not right when he visited on 1 July 2022.

Kevin Collinson said he was initially told that nothing was amiss with his father's dosage, but a few days later a manager at the care home realised that he was being given two 2.5ml doses of risperidone instead of the prescribed 0.25ml twice a day.

The inquest heard the error had occurred as a result of a miscalculation after Mr Collinson's medication changed from being administered in pill form to being given in liquid form.

Samantha Leuty, the manager of Kinmel Lodge, said that, though it was "no excuse", at the time Mr Collinson was one of the first residents to be given their medication in liquid form.

She added the measurements on the syringe provided with the medication had been "unclear", but that practices had since been changed at the care home, with a new digital system introduced for medicine management.

Ms Leuty said that as soon as the error was realised, they contacted the GP, who advised the medication be stopped, and informed the family.

Giving evidence to the inquest, Dr Abdul Karim Tuma, a psychiatrist with Betsi Cadwaladr University Health Board, said he had been involved in the treatment of John Collinson and had visited him a few weeks after the overdose, at another care home where he had been moved.

He added his impression was that Mr Collinson was "ill, physically and mentally" and "very confused, acutely confused over and above his chronic confusion from his dementia", as well as being "not mobile at all".

John Gittins, coroner for north Wales, east and central, said that following the dispensing errors between 1 and 4 July 2022, Mr Collinson became increasingly "sedated and immobile, and at no time did he return to base level of activity".

Following the conclusion, Mr Collinson's daughter, Rhian Collinson, said the family was relieved that the coroner had made the link between the drug overdosing and her father's death, adding it had been a long three years to get to this point.

Kevin Collinson described their father as a happy man and prankster who had enjoyed spending time with his family on walks by the seaside.

He added that his death was premature and they had been "greedy" for more time with him.