Care home resident survived Covid but died when thyroid medication wasn’t restarted

An 87-year-old care home resident who survived Covid against expectations later died when her thyroid medication wasn’t re-started.

Advanced nurse practitioners (ANP) had decided in February last year that great-grandmother Nora Foulkes, from the Vale of Clwyd, should resume taking levothyroxine.

However, the medication was never restarted and the error was missed in later ANP visits.

The pensioner died in Glan Clwyd Hospital in Bodelwyddan five days after being admitted in April last year.

Senior coroner for North Wales East and Central, John Gittins, said her untreated hypothyroidism contributed to her death.

Mr Gittins has issued a report to prevent future deaths to Betsi Cadwaladr University Health Board.

He said: ”Although the original failure to restart the deceased’s treatment for her hypothyroidism would appear to have been discussed and agreed between the Advance Nurse Practitioners and the care home when a medication review was conducted, the deceased was subsequently seen by ANPs on six more occasions between then and her subsequent admission to hospital.

"There were multiple opportunities for this 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.

"Whilst ANPs could access medication charts if required, this was not being done routinely, principally by virtue of time restraint issues.

"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."