A UK coroner has issued a warning to the state-funded National Health Service (NHS) about the dangers associated with identical medication boxes being used by pharmacies following the death of an elderly Indian-origin woman from mistakenly ingesting her husband’s pills.
Sewa Kaur Chaddha, 82, collapsed on the floor of her home at Slough in Berkshire, south-east England, and died in hospital within days in May last year.
She lived with her husband and both had a number of physical health conditions requiring multiple prescribed medications. They also suffered from “cognitive impairment” due to their age.
“It was discovered that she had been taking her husband’s medication instead of her own for several days, including diabetes medication. Her blood sugar levels were found to be extremely low,” Katy Thorne, Assistant Coroner for Berkshire, said in her report published this week.
Chaddha’s cause of death was recorded as hyponatraemia caused by the necessary treatment for hypoglycaemia which was in turn caused by the accidental ingestion of hypoglycaemic medication.
“During the course of the investigation, my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken,” the coroner states in the ‘Prevention of Future Deaths Report’.
Her probe raises a series of “matters of concern”, including the medications being provided to the ageing couple by the local pharmacy in identical dosette boxes or medicine trays except for a small pharmacist’s label with small type-face giving the relevant patient’s name.
“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, or if there was, it was not well disseminated among the pharmacist population,” the coroner said.
“Evidence was given at the inquest 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.” The pharmacies and NHS authorities sent the coroner’s report have a duty to respond with appropriate actions to be taken for future.