‘GP’s neglect’ over repeat prescriptions contributed to care home death – coroner

Neglect by a GP contributed to the death of an 86-year-old woman who was inadvertently given monthly doses of vitamin D tablets every day, a coroner has ruled.

An inquest heard that Eileen Cowles was given her monthly dose of two colicalciferol tablets every day at Primrose Court care home in Guiseley, West Yorkshire (pictured), meaning she was taking 40,000 units of vitamin D.

Witnesses said she died weighing around seven stone, having suffered gastrointestinal bleeding caused by high calcium levels in her blood from the pills.

Wakefield Coroners’ Court was told she started taking a low dosage of colicalciferol twice a month to help boost her bone strength after she fractured her hip in September 2014.

When she was moved to Primrose Court the next month, staff were supposedly instructed by her GP Claire Wiles, from nearby Park Row Medical Centre, that Miss Cowles needed to “take two” of the tablets, without an indication of how frequently, the inquest heard.

Dr Wiles, who had only been a GP for a year when she made the error, also told the care home and the pharmacy dealing with the order that the repeat prescription was correct, a coroner said.

Cancer survivor Miss Cowles was left with hypercalcemia, a condition caused by the presence of too much calcium in the blood.

When her condition started to deteriorate, she was taken to Bradford Royal Infirmary in March 2015, and then St James’s University Hospital in Leeds, but died in April that year.

Recording a narrative conclusion, coroner Jonathan Leach told Miss Cowles’s family on Wednesday that Dr Wiles had failed to carry out basic checks when considering to repeat the prescription of colicalciferol, saying that this contributed to the death.

The coroner said the GP also did not consider whether the dosage and frequency of the medicine was appropriate, and failed to check these elements when the dosage was queried by the care home and the pharmacist.

The coroner told the family: “These failures collectively amounted to a gross failure which caused the deceased’s death.”

He said this failure “constituted neglect” on the part of Dr Wiles, adding that she had failed to check details of the prescription with the hospital where Miss Cowles was treated for the hip fracture.

He said: “She assumed that because that medicine had been prescribed in the past that prescription should continue.

“She did not ask the hospital for a discharge note or ask the hospital for further information.

“She also did not consider what, if any, monitoring was necessary, which would have been apparent from the hospital discharge note or from a query to the hospital.”

Speaking outside the court, Miss Cowles’s daughter, Christine Bull, 68, said she was relieved that those who looked after her mother “have had to explain themselves”.

“Our mum died because five repeated prescriptions were wrong,” she said.

“We hope that people will take note of this, especially because she died of a vitamin D overdose – please always check yours and your family’s prescriptions.”

She added that the verdict had given her family some “closure” following the death of the former pub landlady, who she described as “determined”.

Ms Bull said: “She was strong. We can’t turn the clock back, but it’s been a very long four years for us and I’m now relieved that we can say we did our best for her.”

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