Woman died after taking medicine from husband’s ‘identical’ dosette box

A Berkshire woman with cognitive impairment died after taking medicines from her husband’s dosette box rather than her own “for several days,” a coroner has found. 

A report by assistant coroner for Berkshire Katy Thorne found that Sewa Kaur Chaddha died on May 10 2023, five days after she was found collapsed at home in Slough. 

Both she and her husbands were taking “multiple prescribed conditions” as well as “cognitive impairment due to their age” according to the report. 

The coroner wrote: “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.” 

The cause of death was principally attributed to hyponatraemia “caused by the necessary treatment for hypoglycaemia which was in turn caused by the accidental ingestion of hypoglycaemic medication”.

In her report – which was written in July but made public yesterday (October 15) – the coroner said that both Mrs Chaddha and her husband received separate multi-compartment compliance aids (MCAs) from their local pharmacy, which was then a branch of LloydsPharmacy, adding: “The two patients’ dosette boxes were identical to each other except for a small pharmacist’s label with small type with the relevant patient’s name.”

The inquest found both that there was no “well disseminated” guidance for pharmacies around issuing medicines to patients with dementia and 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”.

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Source: Pharmacy Magazine, 16 October 2024