AN ELDERLY man with dementia died weeks after he was repeatedly given 10 times his usual dosage of his mental health medication at a residential home in Kinmel Bay.
John Richard Collinson died aged 88 on August 30, 2022, having been overdosed for risperidone twice each day between July 1 and 4, 2022 at Kinmel Lodge, on Betws Avenue.
Mr Collinson’s family moved him out of Kinmel Lodge shortly after this became apparent; he then died at Pembroke House care home in Colwyn Bay, where he was moved for end-of-life care.
An inquest at County Hall, Ruthin today (June 30) heard that miscalculations when converting Mr Collinson’s risperidone from tablet to liquid form caused the overdoses.
Though, the home’s manager, Samantha Leuty, said the first she heard of it was during the morning of Monday, July 4, after staff who had worked the previous weekend raised no concerns.
The inquest heard that Mr Collinson, who lived in Llanfairfechan, ran a fish and chip shop, and was described as a “very loving, caring man” by his son, Kevin, began residing at Kinmel Lodge in August 2020 following issues with his cognitive functions.
But at the start of July, Mr Collison was given 2.5ml of the drug, instead of the correct amount of 0.25mg, twice a day.
This total daily dosage of 5ml of risperidone was described by both a pharmacist and a nurse at the inquest as exceeding the “maximum daily dosage”.
Only weeks earlier, his son said, Mr Collinson had been “dancing and singing” at a party at the home to celebrate Queen Elizabeth II’s Platinum Jubilee.
The repeated overdoses “wiped him out” and rendered him “comatose”, his son added, while Mr Collinson also developed a bedsore on his left heel which “left him in agony”.
“After that medication, he never walked unassisted again,” Mr Collinson’s son told the inquest.
“He was essentially bedridden, apart from getting into a chair.”
Dr Tuma Abdul Karem Tuma, a consultant psychiatrist for Betsi Cadwaladr University Health Board at the time, said it was “very likely” that the overdose caused Mr Collinson’s reduced mobility.
When he met Mr Collinson on July 20, when he was residing at Llys Elian care home in Colwyn Bay, he said he appeared “very unwell physically and mentally”, and “acutely confused”.
Ms Leuty, manager of Kinmel Lodge, said Mr Collinson was “one of the first” residents at the home to be given medication in liquid form, but stressed this was “no excuse”.
She said she immediately contacted Mr Collinson’s general practitioner after being made aware of the overdoses on July 4.
Asked whether this could have become apparent sooner, Ms Leuty said: “You could say yes; however, he had presented like this before, after a urinary tract infection.”
She added the home has “learned a very hard lesson,” and now conducts weekly audits instead of monthly, having carried out its own internal “in-depth investigation”.
Multiple members of senior management staff must also now sign off on medication being prescribed to residents, Ms Leuty added.
Priya Ellson, Kinmel Lodge’s owner and responsible individual, said it now works with a new pharmacy, and has moved to a new care planning system.
All staff involved with Mr Collinson’s case were issued with “refresher training”, while there have been no similar issues at the home since.
John Gittins, senior coroner for North Wales (East and Central), recorded a narrative conclusion, and said it is “probable” that Mr Collinson’s decreased levels of mobility following the overdoses “more than minimally” contributed to his death.
A cause of death was recorded of bilateral pulmonary emboli due to deep vein thrombosis, with immobility following medication error stated as a contributory factor.
Mr Gittins refrained from issuing Kinmel Lodge with a Prevention of Future Deaths report, saying he felt satisfied that the home had “wholly accepted” and addressed the error.
Speaking after the inquest, Mr Collinson's daughter, Rhian, said his family "lost everything about the way he was" after his overdoses.
His son, Kevin, labelled his death "premature", and said he and his siblings have "had to fight for our father's dignity".
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