Pensioner dies ‘after being given wrong medication at care home’

Roy Henshaw, 84, was given another resident’s medication by a distracted care assistant and within two hours he started having fits.

An ambulance was called and he was rushed to Doncaster Royal Infirmary but died the next day from pneumonia.

Police were called in to investigate at the Royal Care Home in Rossington, Doncaster, and arrested a woman on suspicion of manslaughter but no charges were ever brought. Mr Henshaw’s family told the hearing that they did not blame the care assistant, Abbie Tang, and a forensic toxicologist could find no link between the incorrect medication and the death.

In delivering her narrative verdict coroner Nicola Mundy said that Mr Henshaw had developed a “significant tachycardia”, or irregular heart rhythm, following “incorrect administration of medications.”

She went on: “Immobility arising out of the consequent medications led to his death from a severe chest infection.”

Mr Henshaw, who suffered from hypertension and dementia, had been in the home since January 2009. He was on a cocktail of four drugs for blood pressure, anti-seizure, constipation and nausea. Mrs Tang told how she was doling out the medication to residents from a trolley on November 7 that year when she began talking to a nurse.

She said: “I saw his face and I made the assumption that the medication was for Roy.

“I can’t remember which medication I gave to him.”

She realised her error “almost straight away” and told the hearing: “My first reaction was ‘oh my God’ what shall I do about this?”

She saw to the other residents then rang on-call Dr Wijayasena Dahanayake from the nearby Rossington Practice for advice.

She was told to monitor Mr Henshaw’s condition and administer the correct drugs. Senior staff and the family were informed. But Mr Henshaw quickly developed a high heart rate. An hour later he had a seizure.

His condition worsened and he died the following day.

Forensic toxicologist John Slaughter said that none of the drugs wrongly administered were particularly toxic and all were in low doses.

He said: “I have no reason to believe that this wrongly administered medication has any bearing on Mr Henshaw’s death.”

Pathologist Professor Peter Vanezis said that the drugs he was mistakenly given could have increased his heart rate and led to oxygen starvation which could have caused the “twitching and fitting”.

But he was unsure when Mr Henshaw contracted the infection. He gave the cause of death as lobar and bronchial-pneumonia.

Investigating officer Det Con Paul Rooney said that he had looked into whether a criminal offence had taken place. He said: “We decided there were no suspicious circumstances surrounding the death and there was no third party involvement.”

Since Mr Henshaw’s death, health care assistants have been stopped from administering medication at the home.

It is now solely the responsibility of nurses.

Ms Mundy said that the immediate cause of Mr Henshaw’s death was pneumonia.

After the hearing Mr Henshaw’s nephew Trevor Henshaw said: “The young lady who administered the wrong medication was absolutely brilliant with my uncle.

“We accept what was said at the inquest that the wrong medication did not contribute to his death.”