NURSING homes must ensure that medication is “kept under lock and key” at all times, coroner Dr Tony Casey has recommended following the death of a resident of a west Limerick care centre.
There was “no evidence”, Dr Casey stressed, that the late Kathleen O’Doherty had actually overdosed by taking two pods of medicine that were intended for two other patients at Cahermoyle Nursing Home in Ardagh on January 27, 2013.
The missing pods - which contained eight different drugs - were never found after what staff nurse Marie McLoughlin said was an “extensive search”.
Ms McLoughlin told the inquest she had left a box of gloves over a tray on which the medicine lay while she went to deal with another wandering resident. When Ms McLoughlin returned, the pods were missing but she couldn’t be sure whether Ms O’Doherty had taken the drugs.
Ms McLoughlin had reported the missing medication to Shannondoc and to University Hospital Limerick to ensure those caring for Mrs O’Doherty had a complete picture.
Dr Casey said the missing medication made this case a suspicious death and recommended that in all similar cases in future, the hospital should report such deaths to him, as it was “obliged to do under law”. He noted that as coroner, he had only become aware of the death when it was reported to him by HIQA five days after Ms O’Doherty died on January 31, 2013. She had already been buried and no post-mortem examination had been carried out.
Dr Margaret O’Connor, consultant geriatrician, said that Mrs O’Doherty had chronic pulmonary and respiratory disease and had been managed palliatively from December 2012.
An open verdict was recorded.