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Trust admits neglect after patient died when unsupervised HCA administered drug


Birmingham and Solihull Mental Health NHS Foundation Trust has accepted that it was at fault following the death of a patient who was administered a drug by an unsupervised healthcare assistant during a home visit.

A trust board report, published on 26 September, revealed that the healthcare provider was at fault in the death of a woman in December 2015.

“Our trust fully accepted the findings of the inquest into the death”

John Short

Patricia Cleghorn, who died from an “intentional overdose”, was in the care of the trust’s home treatment team, while waiting for voluntary admission to an inpatient bed.

She was administered a controlled drug by an unsupervised healthcare assistant. The “preventing future death” report said Ms Cleghorn was administered 5mg of diazepam by an HCA working for the team.

The report said: “This [drug] had a dramatic effect on her which was not appreciated by the healthcare assistant, despite questioning by her husband and soon after this she was found collapsed, an ambulance was called but she was declared dead by the paramedics.”

The trust confirmed the HCA was not being directly supervised on the visit and this was not in line with its medicines code.

The document also said Ms Cleghorn was “unlikely” to have died when she did had she been admitted to hospital, and she was left at home “self-medicating”, despite “repeatedly stating she would end her life by taking an overdose”.

The report said that no formal risk assessment was made by the trust and the staff involved had failed to appreciate what drugs Ms Cleghorn had available to her.

Following her death, the trust took a number of steps including reminding registered and non-registered clinicians in their crisis and community teams the requirements for:

  • Clinical risk assessments regarding risk of self-harm and suicide
  • Risk assessments regarding medicines management and self-medications
  • Safe administration of medication in line with the trust’s medicines code and Nursing and Midwifery Council code, including clarifying the role of non-registered staff in crisis teams to ensure that tasks delegated to them are within their sphere of competence

The trust said it would review its medicines code “to ensure that the issues highlighted by our investigation are properly considered and addressed in a revised code”. It has also ensured that patients waiting for access to inpatient beds receive “enhanced care”.

Trust chief executive John Short said that, while the trust had taken steps to improve the flow of patients through inpatient beds, the availability of acute mental health inpatient beds was a “national issue”.

Birmingham and Solihull Mental Health NHs Foundation Trust

Patient died after unsupervised HCA gave drug, says trust

John Short

This was raised by the coroner in a letter to the Department of Health, NHS England and the Care Quality Commission. Mr Short said: “Our trust fully accepted the findings of the inquest into the death of Patricia Cleghorn.

“Following this tragic incident, we carried out a thorough investigation which has led to a number of actions to improve the assessment of risk and reinforce requirements for the safe administration of medication by appropriately qualified staff,” he said.

“We apologise to Ms Cleghorn’s family for the shortcomings in the care we provided to her and our thoughts remain with them following their loss,” he added.


Readers' comments (20)

  • And so it starts
    I have worked in care home where HCAs have been 'trained' to administer drugs. What I have seen horrifies me. HCAs seem to think because they have had some training with Boots or others they are nurses
    Medicine audits done by HCAs are a sight to behold. If one box is short take some from a box where there is more that there should be. Dead residents drugs are a godsend, tucked away out of sight to be usd in shortfalls in medicine audits.
    It is not a safe practice

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  • OMG.... if this HCA's was a Registered Nurse he/she would now be struck off the NMC register, but of course HCA's are NOT on a register.

    I was unable to re validate my NMC registration after fighting 4.5 years injustice of false allegations of bullying and not in the workplace to tick the re validation (waste of time) boxes.

    The Nurse (qualified) who was present when the HCA gave the controlled drug IS RESPONSIBLE and must be held accountable FOR THE HCA'S ERROR.

    Perhaps I should apply for HCA's job - lol x

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  • The end of Nursing career and more dead bodies.

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  • In the next 2 years when nursing assistants would be able to administer drugs,who would be held responsible?

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  • This was my whole point about Band 4 giving drugs. Who will hold the baby the registered nurse of course how about the NMC get involve of course not the HCA is not registered!. A trained nurse would of been drawn and quartered by the NMC. The noose would be tightened by the managers or the trust.

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  • Before we criticise all HCA's who often do a brilliant job within the confines of their role and hopefully with a supportive, skilled team of registered nurses supervising and working with them I have to ask myself why was a HCA allocated to work unsupervised with such a high risk patient. I agree that carrying out a task that was outside her role, skill and ability should not be ignored but who put her into this situation and why. I am sure HCA would not just visit patients as and when they felt like it or where staff shortages workload pressures a factor. A tragic situation.

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  • Some band 4 community HCA's administer and are not regulated, perhaps this will be a wake up call for the new NA role

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  • Can I say that in complex care packages out in the community: by complex I mean trachy/vent, PEG, spinal bowel care procedures. This also includes the giving of medication via the PEG...all this is done by Support Workers - all of it! and it is done very well.
    I am a nurse and would say to some get over yourself about medication it is all in the training and the calibre of staff you employ.
    The NMC needs to re think this accountability anomaly the HCA's and Support workers are liable in law (like anyone else) for their actions - their employer is liable for training supervision etc. I say employer not the nearest RN....

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  • What was the cause of death?
    5mg diazepam is a small amount.
    What else was happening?

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  • michael stone

    ANONYMOUS 4 NOVEMBER, 2016 0:22 AM

    Yes - I only scanned this article, but my immediate thought was also:

    'I have to ask myself why was a HCA allocated to work unsupervised with such a high risk patient'

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