Prevention of Future Deaths report: Sewa Chaddha (15 October 2024)

Summary

On 27 March 2024 an investigation took place into the death of Sewa Kaur Chaddha, then aged 82. Mrs Chaddha had been living with her husband in Slough. They both had a number of physical health conditions requiring multiple prescribed medications. They both had cognitive impairment due to their age.

On 5 May 2023 Mrs Chaddha was found collapsed on the floor at their home. It was discovered that she had been taking her husbands medication instead of her own for several days, including diabetes medication. Her blood sugar levels were found to be extremely low.

She died on 10 May 2023 at Wexham Park Hospital of hyponatraemia caused by the necessary treatment for hypoglycaemia which was in turn caused by the accidental ingestion of hypoglycaemic medication.

The investigation concluded at the end of the inquest on 24 May 2024. The conclusion of the inquest was accident, the medical cause of death being:

• I a Hyponatraemia
• I b Treatment for hypoglycaemia
• I c Ingestion of hypoglycaemic medication
• II Frailty of old age, decompensated heart failure, cognitive impairment.

Content

Matters of Concerns

• The medications were provided to the couple by the local pharmacy, then known as Lloyds Pharmacy, in separate dosset boxes. Mrs Chaddha’s medications were provided on a weekly basis. Mr Chaddha’s were provided on a monthly basis.
• Both patients were elderly and had cognitive impairment.
• (The two patients’ dosset boxes were identical to each other except for a small pharmacist’s label with small type with the relevant patient’s name.
• Mrs Chaddha used one of Mr Chaddha’s dosset boxes, rather than her own, for several days.
• 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.
• Evidence was given at the inquest that dosset boxes of different colours or labels with different colours were not routinely given to elderly or cognitively impaired patients living at the same address.