A FAMILY from Conwy have called for change in the administering of medication in care homes after an elderly man died weeks after being repeatedly given 10 times his usual dosage.
John Richard Collinson, who had dementia and was from Llanfairfechan, died aged 88 on August 30, 2022, having been overdosed for risperidone twice each day between July 1 and 4, 2022 at Kinmel Lodge in Kinmel Bay.
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 in June heard miscalculations when converting Mr Collinson’s risperidone from tablet to liquid form caused the overdoses.
Coroner John Gittins found it was “probable” that Mr Collinson’s decreased levels of mobility following the overdoses “more than minimally” contributed to his death.
Now, Mr Collinson’s family are urging more stringent measures in how medication is administered, and more accountability from care home owners.
His son, Kevin, said: “The people who gave my dad risperidone were not medically qualified to do so. There’s a loophole there.
“This is really serious medication. Should they not be medically qualified to administer it? Staff there work long, stressful shifts. Were they getting sufficient breaks?"
Mr Collinson said his family's experience raised wider issues and he hopes that lessons can be learned.
He said: “As a family, we have also exhausted the legal paths, and nowhere does the process hold company owners to account."
North Wales Police said Mr Collinson’s death was investigated by the force, but resulted in no further action being taken due to “no criminal offences being identified”.
Kevin has also met with his MP, Claire Hughes (Bangor Aberconwy), to raise his concerns.
He said: “I have been a company director before. When things went well, I got the plaudits. When things went wrong, I got criticised.
“With care homes, it doesn’t seem to work like that."
In response to Kevin’s comments, Welsh Government said the All Wales Medicines Strategy Group has published guidance to support care providers with safe, effective management of medicines in the community.
This can be read at: awttc.nhs.wales/files/guidelines-and-pils/all-wales-guidance-to-support-integrated-medicines-management-in-community-settings-pdf.
A Welsh Government spokesperson said: “Prescribed medicines can be administered safely by people who are competent to do so and follow the directions given by a prescriber.
“Social care workers receive training in administering medicines and care providers must have arrangements in place to assure themselves of the competence of their workforce when performing such tasks.”
Following the inquest, Care Inspectorate Wales (CIW) said it “identified significant concerns” at Kinmel Lodge after this incident and took enforcement action.
But the organisation said it now feels “assured the necessary improvements had been made”.
A CIW spokesperson said: “We would like to again extend our sincere condolences to the family and loved ones of John Richard Collinson.
“This was a deeply tragic incident, and our thoughts remain with his family.
“When CIW inspects a service, we inspect against the regulation and inspection of Social Care (Wales) Act 2016; specifically, regulation 58 of the accompanying statutory guidance which includes requirements for safe medication management.
“All registered services must have robust policies and procedures covering ordering, storage, administration, recording and disposal of medicines.
“Although we can’t comment on the legislation itself, if a service does not meet regulatory standards, we will take action.
“CIW is committed to ensuring everyone receives safe, high-quality care, and we will not hesitate to act where services fall below expected standards.”
Kinmel Lodge was approached for comment.
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