On the 11th July 2013, I commenced an investigation into the death of Derrick George RIVERS then aged 89 years of Passmonds Care Home, Edenfield Road, Rochdale; Greater Manchester The investigation was concluded at the end of the inquest on the 28"h February 2014. conclusion of the inquest was narrative: the deceased died as a result of natural causes, to which the administration of Clozapine may have contributed. The medical cause of death was 1a) Ischaemic Heart Disease

The deceased had become increasingly frail and following a fall, a decision was taken to arrange his admission to full time care_ Initially, Mr Rivers settled well and was able to self-medicate: However; shortly after admission the care home Stafa felt that he could no longer manage this aspect of his care independently and assumed responsibility for the task On the morning of the 3r4 July 2013, the senior carer was engaged in the process of administering medications to residents_ During the course of round she erroneously administered a 150mg dose of Clozapine to the deceased_ This was an anti-psychotic medication meant for another resident; it was not a controlled drug but was treated as such by the care home staff due to its potency: The error was noted immediately and the emergency services summoned The deceased was admitted to hospital suffering from altered level of consciousness and confusion; After a nueber of days the Mr Rivers showed improvement in his overall condition and discharge planning was set in motion: Unfortunately; in the early hours of the 11" July he deteriorated and died later the same day: A forensic post mortem examination was carried out The Dr concluded that the deceased died of natural disease process_ However she was not able to completely exclude the possibility that the dose of Clozapine had not exacerbated this (thus hastened death) Furthermore; it was evident at post mortem that the deceased had a degree of liver impairment: Given this, the Dr concluded that it was possible that the deceased's body systems may have taken longer to clear the drug: The care home and Local Authority Adult Safeguarding Team carried out their own investigations; The carer was demoted for to follow the care home's protocols on administration; The Chair of the Case Confecence concluded that it was the consensus of the case conference that there had been 'physical' abuse and there was a majority consensus as to 'institutional abuse" as defined within the strict terms of its detinitions . The Care Home owner reluctantly accepted the former_but not the latter The the drug failing

(Head of Medicine Management at the Clinical Commissioning Group, who was invited by the Local Authority to assist in the investigation process) gave evidence that the administration policy used by the care home was inadequate and a number of patient safety issues were identified when he inspected on the 5th July 2013. Immediate recommendations were made Whilst some remedial actions were taken, not allhis recommendations had been implemented by the time of his second inspection on the 5th September 2013_ considered that further work needed to be done to reduce the future risk of maladministration of medicines both at the care home and borough-wide: also stated that whilst the CQC is able to carry out medication reviews as part of its inspection process it had not done so as part of its most recent inspection of the care home; Had it done s0, opined that the situation involving Mr Rivers might have been avoided He was of the view that subsequent inspections should not only address Outcome 9 but also that the medication audit should be conducted on an annual basis concluded by saying that the dose of Clozapine administered was more than ten times the normal starting dose of 12.5mg and that given its potency, the potential for harm from a 160mg dose was high and would, in his view, have had catastrophic consequences even for someone much younger than the deceased