Painkilling patches were missed by care home nurse

A nurse failed to find two patches containing painkiller drugs on the body of a Newark woman before attaching two more, an inquest in Nottingham was told.

Four fentanyl patches, a potent controlled drug, were found on Mrs Lil Elvidge when she was taken to hospital from Red Rose Nursing Home, Farndon, five days after being admitted there for respite care.

Mrs Elvidge, 77, of Pelham Street, died on December 11, 2010, the day after being admitted to King’s Mill Hospital, Sutton-in-Ashfield.

The deputy coroner for Nottinghamshire, Mrs Heidi Connor, on Tuesday recorded a narrative verdict.

She said the primary cause of death was multiple organ failure but she was satisfied that the fentanyl overdose played a material part.

Mr John Elvidge said his wife was prescribed fentanyl patches to help with a host of health problems.

He said two patches with a combined dosage of 87microgrammes had to be administered every 72 hours but it was important that old ones were removed to ensure the prescribed dose was not exceeded.

Mrs Elvidge, who used to help run the Midland Hotel, Newark, with her husband and was then a caretaker at the town’s courthouse, was admitted to the nursing home on December 6 because of mobility problems.

On the fifth day of her stay her family became concerned at how her health had deteriorated and asked a nurse for help.

She took her temperature and reassured the family it was normal but Mr Elvidge said they continued to be concerned and asked for a doctor.

He said their GP surgery was eventually called and a doctor said Mrs Elvidge should be taken to hospital.

Miss Saiby Thomas, a bank nurse working at the nursing home, said that on December 9 she attended to Mrs Elvidge because she knew her fentanyl patches needed to be replaced.

She said she could not find the old patches on Mrs Elvidge’s body and knew that on occasions patches had fallen off.

She looked on the bed and floor but there was no sign of the patches and attached two more.

Other nurses at the home gave evidence in which they said they would have dealt with the situation differently, making a thorough body search for the patches and seeking help from colleagues.

Dr Jill Woodhead, a consultant at King’s Mill Hospital, said she was surprised to find four fentanyl patches on Mrs Elvidge when she was admitted.

But she said she felt Mrs Elvidge had been more at risk from acute renal failure than from a fentanyl overdose.

Independent witness Dr Roger Knaggs, an advanced planning practitioner in pain management, said the patches still contained medication for up to 72 hours after they needed to be replaced.

But he said that given Mrs Elvidge’s medical history she would probably have died even if the extra patches had not been attached.

Mr Mick Brownhill, nursing home manager since June, said that protocols were in place over the application, removal and disposal of patches and what should be done if they were missing. He said regular assessments ensured they were complied with.