Medication Box Mix-Up Leads to Death of Elderly Woman, Coroner Issues Warning

A coroner in the UK has issued a serious warning to the National Health Service (NHS) regarding the dangers of pharmacies using identical packaging for medications, following the death of Sewa Kaur Chaddha, an 82-year-old Indian-origin woman. Chaddha mistakenly consumed her husband’s medication over several days, resulting in her death in May last year.

Sewa Kaur Chaddha, who lived with her husband in Slough, Berkshire, collapsed at home and was rushed to a hospital, where she died within a few days. Both she and her husband had multiple chronic health issues that required numerous prescribed medications. Due to their advanced age, they both also suffered from cognitive impairments, which further complicated their ability to manage their medications effectively.

According to Assistant Coroner Katy Thorne, Chaddha had been inadvertently taking her husband's medication instead of her own for several days. Among the medications she consumed was her husband’s diabetes medication, which significantly lowered her blood sugar levels, a condition known as hypoglycemia. Her blood sugar had dropped to critically low levels before she collapsed. The official cause of her death was determined to be hyponatraemia, a condition caused by the treatment required to counteract her hypoglycemia, which was itself triggered by the accidental ingestion of her husband's hypoglycemic medication.

During her investigation, the coroner identified several concerns that could pose risks for future deaths unless corrective action is taken. In her official report, called the ‘Prevention of Future Deaths Report,’ Thorne warned that without changes, similar tragedies could occur again. Her inquiry highlighted that elderly couples, especially those with cognitive impairments, were particularly vulnerable to medication errors when their medications were provided in similar packaging.

One of the primary issues raised in the report was the use of identical dosette boxes (medicine trays) by the local pharmacy for both Chaddha and her husband. These boxes only differed in the small pharmacist’s label that identified the patient’s name, printed in a small typeface. The coroner’s report expressed concern that this labeling method was insufficient for elderly patients who might struggle to differentiate between the boxes, particularly those with cognitive impairments.

The inquest revealed that there were no specific guidelines or protocols in place for pharmacists to follow when dispensing medications to patients with cognitive challenges. While such policies may exist, they had not been properly disseminated among pharmacists, leaving a gap in the system that contributed to the tragic outcome.

Further evidence presented at the inquest noted that the use of color-coded dosette boxes or brightly labeled packaging for elderly or cognitively impaired patients living together was not a common practice. The coroner recommended that such practices be considered to help prevent similar incidents in the future. Simple changes like using different colors or distinctive labels for medications could potentially save lives by helping patients more easily identify their prescribed drugs.

The report has now been forwarded to the relevant NHS authorities and pharmacy bodies, who are required to respond with appropriate actions. They are expected to implement necessary measures to prevent future errors, particularly among elderly and vulnerable patients.

This case has raised broader concerns about the safety protocols in place for dispensing medications, especially for patients with cognitive impairments who are more likely to make dangerous mistakes. The coroner's findings underscore the importance of clear labeling and additional precautions for this vulnerable group to reduce the risk of fatal medication errors.

(Input from various sources)

(Rehash/Yash Kamble/MSM)