Coroner Katy Thorne shared concerns about a patient who took medicine from her husband’s dosette box “rather than her own, for several days” with seven industry bodies, coroners’ court documents published this week (October 15) revealed.
The Berkshire assistant coroner said that 82-year-old Sewa Kaur Chaddha “had been living with her husband in Slough” at the time of her death.
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“They both had a number of physical health conditions requiring multiple prescribed medications” and “both had cognitive impairment due to their age”, Thorne said.
“The medications were provided to the couple by the local pharmacy, then known as Lloydspharmacy, in separate dosette boxes,” she added.
But “Mrs Chaddha was found collapsed on the floor at their home” on May 5 2023, she said.
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“It was discovered that she had been taking her husband’s medication instead of her own for several days, including diabetes medication” and “her blood sugar levels were found to be extremely low,” the report revealed.
Chadda died in hospital five days later of “hyponatraemia caused by the necessary treatment for hypoglycaemia which was in turn caused by the accidental ingestion of hypoglycaemic medication,” it added.
“No guidance” for pharmacists
Thorne said that the case had “revealed matters giving rise to concern”.
Although “both patients were elderly and had cognitive impairment”, their “dosette boxes were identical to each other except for a small pharmacist’s label with [their name in] small type”, she added.
“Evidence was given at the inquest that there was no guidance or policy in place for pharmacists to follow when issuing medication to patients with cognitive impairments,” she said.
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“Or if there was, it was not well disseminated among the pharmacist population,” she continued.
She added that evidence was given that “dosette boxes of different colours or labels with different colours were not routinely given to elderly or cognitively impaired patients living at the same address”.
“Tragic confusion”
Responding to the concerns in a letter to Thorne, the General Pharmaceutical Council (GPhC) said it had “published a series of equality insight articles…designed to support pharmacy teams” and had “recently published information” about providing services to patients with dementia.
It added that “through this communication, [it] highlighted” that such dosette boxes “may not always simplify how people with cognitive impairment take their medicines”.
“Thank you for raising this matter with us and we will consider how we can continue to raise awareness of these important issues,” the GPhC added.
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Community Pharmacy England (CPE) said that it was aware of “recent and comprehensive guidance on [dosette boxes] published by the Royal Pharmaceutical Society (RPS)”.
But it added that it was “not aware of any explicit guidance or encouragement for pharmacists and pharmacies” to differentiate dosette boxes given to cognitively impaired adults living at the same address and “avoid the potential for the tragic confusion that occurred in this case in this household”.
CPE said it would “bring the concern” to the RPS and the Community Pharmacy Patient Safety Group (CPPSG) and “ask each to consider additional guidance”.
Pharmacists “rarely receive any information”
The National Pharmacy Association (NPA), which was also sent a copy of the report, said it was “very saddened to hear about” the death of Chaddha, but stressed that “Lloydspharmacy - who provided medication to Mrs Chaddha - is not/was not an NPA Member”.
“We will review our existing guidance and consider how we can refine it,” it added.
The NHS Specialist Pharmacy Service (SPS) told Thorne that it would “consider” changing its training resources “to recommend that medicines are clearly labelled for differentiation between household members, particularly for patients who are elderly and/or have cognitive impairment”.
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Responding to Thorne, NHS Frimley Integrated Care Board (ICB) said that her report “did not include details of whether any assessment had taken place to establish the support required by Mr or Mrs Chaddha”.
It stressed that community pharmacies typically “rarely receive any information about diagnoses or social care details” of patients.
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“As a result of this case, the ICB will be updating local resource material to remind healthcare professionals of the importance of carrying out an assessment”, including considering “other people in the home that may also have additional needs”, it said.
Berkshire ICB and the Medicines and Healthcare products Regulatory Agency (MHRA), who were also sent copies of the report, declined to comment.
And C+D also approached Slough Pharmacy and Lloydspharmacy’s former parent company Hallo Healthcare for comment.
