Coroner says action should be taken after care home death

Inquest's findings

An inquest had found that Beryl Ellison, who “was in declining health and was receiving end of life care” at Alexandra Care Home, in Newton-le-Willows, had died “as a consequence of her underlying poor health in combination with taking an excessive quantity of her prescribed medication”.

Mrs Ellison had previously suffered with pneumonia and septicaemia, and had an amputation of her leg and finger due to blood clots.

On June 28, 2022, at around 10am,  she had been due her medication, and one of the care workers went into her room, as it was “unusual” for Mrs Ellison not to have not pressed the call button for her medications before this time. Mrs Ellison was found to be “very drowsy and sleepy”.

The care assistant took her observations, which were “concerning” and informed the staff nurse before calling for an ambulance.

However, as the care assistant returned to the office to make her call, the nurse informed her that Mrs Ellison had already died.

Police and Mrs Ellison’s GP were called to the home on Wargrave Road, Newton-le-Willows, and her death was pronounced at 1.52pm.

'Action should be taken'

A Regulation 28 Prevention of Future Deaths report, following the conclusion of the inquest into Mrs Ellison’s death in December, has been sent to the care provider Four Seasons Healthcare by assistant coroner for St Helens, Knowsley and Sefton, Johanna Thompson.

These are issued when a coroner believes actions should be taken by an organisation to prevent further deaths.

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The report said that about four to six weeks before her death, “Mrs Ellison’s son stated he had raised a concern to the care home about medication being left in his mother’s room, as she had been observed hiding it under the bed covers”.

It added Mrs Ellison’s son “had been informed that the staff would administer the morphine and observe her taking it from then on”.

The report noted “Mrs Ellison’s son was concerned that there had been no change in the care home practice since his earlier complaint, which may have led to his mother taking an accidental overdose of her medication”.

In the report, the assistant coroner added that Mr Ellison’s family “expressed concern that she had been left with syringe medication unsupervised by staff and raised concerns about this with the care home both historically and four days prior to her death”.

Mrs Ellison was found to have “an excessive concentration” of medication in her system “which was likely to exceed any acquired tolerance level”. 

It was said “evidence heard at inquest revealed no explanation” for why Mrs Ellison had the excessive amount of medication in her system.

In the report, the coroner concluded: “In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action”.

The Care Quality Commission says it is gathering necessary information in line with our regulatory powers after Mrs Ellison's death (Image: Stock)

'We are gathering all necessary information'

A Care Quality Commission (CQC) spokesperson said: “CQC are aware of the sad death of someone living at Alexandra Care Home in Newton-le-Willows, and our condolences are with the family.

“We are gathering all the necessary information regarding the death to determine our next steps in line with our regulatory powers.

“CQC’s priority, at all times, is the health and wellbeing of people using health and social care services, and all information we receive informs our monitoring of services and future inspections.”

The Star has approached care provider Four Seasons Healthcare for a comment over the matter.

A Four Seasons spokesperson has previously told media: “The safety and well-being of our residents will always be our utmost priority.

“We are currently in the process of working transparently with the relevant authorities regarding the passing of Mrs Beryl Ellison.

"Our thoughts are with the family at this sad time.”