A FAILURE to resume medication when a pensioner returned to a care home from hospital contributed to her death.

Now, because of concerns arising from the case, John Gittins, senior coroner for North Wales East and Central, has issued a Prevention of Future Deaths (PFD) report.

Nora Foulkes, 87, died at Glan Clwyd Hospital, on April 16, 2021, and at an inquest the coroner recorded a narrative conclusion outlining the circumstances.

Mrs Foulkes contracted COVID-19 in December 2020, while living in a residential home, but managed to survive.

And in February 2021, visiting Advanced Nurse Practitioners (ANPs) decided that the levothyroxine medication she had been receiving for hypothyroidism should be restarted.

However, although the information was passed on to the home, it was not recommenced and the failure was not picked up on subsequent visits by ANPs.

On April 11, Mrs Foulkes returned to hospital but died five days later.

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A post-mortem examination revealed the cause of death as cardiorespiratory failure, which was the result of bronchopneumonia and an existing cardiac condition, but that her untreated hypothyroidism had contributed to her death.

In his PFD report to Betsi Cadwaladr University Health Board, Mr Gittins said there had been “multiple opportunities” for the error to be spotted and corrected.

“But this did not happen because at those visits there was no consideration being given by the ANPs to the patient’s medication regime to ensure that appropriate treatment was being provided,” he said.

Largely because of time restraints, the ANPs did not check Mrs Foulkes’ medication charts during their visits.

“I am concerned that the absence of proper scrutiny or review of the medication of elderly patients in care homes during each visit presents a risk to life as it can lead to the type of error which occurred in this case not being identified,” he added.

The health board has until June 9 to respond to the report.