Kim Stroud
22 Feb 2024 · Coroner Yvonne Blake · Norfolk
The coroner's concerns
1. medication administration errors
“Mrs [name redacted] care appears to have been non-compliant with both hospital policies and the Nursing and Midwifery Council regulations for the administration of medication”
2. unsupervised medication administration
“Mrs [name redacted] had delirium and could not be left to take them herself”
3. medication access by other patients
“There were other confused and mobile patients on the same ward who could have picked them up”
4. inadequate incontinence care
“Mrs [name redacted] was found in her bed so soaked in urine (I have seen photographs of this) that the urine was dripping off the edge of the bed and the family had to wash and change her themselves.”
5. family burden of care tasks
“the family had to wash and change her themselves”