Nora Foulkes

“Although the original failure to restart the deceased's treatment for her hypothyroidism would appear to have been discussed and agreed between the Advance Nurse [name redacted] and the care home when a medication review was conducted, the deceased was subsequently seen by ANPs on six more occasions between then and her subsequent admission to hospital and as a result there were multiple opportunities for this error to be spotted and corrected but this did not happen because at those visits there”

“I am concerned that the absence of proper scrutiny or review of the medication of elderly patients in care homes during each visit presents a risk to life as it can lead to the type of error which occurred in this case not being identified”

“Whilst ANPs could access medication charts if required, this was not being done routinely, principally by virtue of time restraint issues”