Duplicate Medication dispensed by home

My Mum is in assisted living (she has dementia). The home duplicated her medication (do not know which one yet) and sent her to hospital approximately 3 hours later. They contacted my friend when she was on the way to hospital who let me know, but they did not inform me. Poor Mm was quite distressed, confused as she had no idea why she was being sent to hospital. The home made the decision to send her to hospital without consultation with me, they woke her up at midnight to send her with the paramedics but no one from the home accompanied her. I’m asking questions but still awaiting answers but I have been told that because it’s assisted living they would not expect to accompany her to hospital.

Mum was given the all clear, the Dr told my friend that the dose was not in the toxic range. I am questioning the home about what they had based their decision to send her to send her to hospital. She is new to the home and was already having problems settling, this may make it worse.

Am I being unreasonable to expect, where an error is caused by the home, they should have a moral responsibility to ensure that everything is done to mitigate the psychological damage to the resident?

Any other thoughts on this?

Oh, and the paramedics have requested an inquest on how the duplication of medication happened in the first place.

Very glad your mum wasn’t harmed by this serious error. To my mind, if the home staff caused the double dose then someone from the home ought to have accompanied your mum, especially since she has dementia. It wouldn’t surprise me if the paramedics hadn’t instigated a safeguarding case. I think they would have been so obligated. I think you ought to complain to the cqc and call it a safeguarding issue. Alternatively, or both, contact the local authority’s adult safeguarding team.

It makes me wonder that, either the Medication Administration Record was wrong, or the person who gave your mum her medication hadn’t checked the MAR chart first, or that the first person failed to record the first dose and so a second was given, or she was given the wrong strength pill. Whatever happened the home needs to do a full investigation, followed by retraining.

Depending on who the contact(s) are listed on your mum’s records, the home needed to contact atleast one of them I suspect the home wanted to get your mum to hospital asap since they recognised it as an emergency.

I’m most surprised añd appalled that no one from the home went with your mother. How was she supposed to tell medical staff why she was there. She had no idea a mistake had been made. Of course they should let someone know. Priority to get her to the hospital with someone who could explain. More than one error made and needs investigation.
Pleased the hospital found nothing serious.
My late husband’s nursing home always sent someone with him, and any other resident. Caused staff shortage but they had to find agency staff.

Sorry to read this! Let us know what happens with the investigation. At least this is being taken seriously.

Notify CQC, it may not be the first time this has happened at this home.


Hi again. By iniating a safeguarding case either with CQC or directly to the Local Authority social services, you are making the carehome accountable to the LA. The care home won’t be able to keep the incident to themselves to handle.

Did they have your friend’s contact info because your primary home is in Canada?