‘Catalogue of errors’ led to overdose

Vivienne Jones
Vivienne Jones
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The family of a woman who died following an overdose of prescription drugs are urging health chiefs to learn lessons after claiming that a ‘catalogue of errors’ led to her death.

Vivienne Jones, 55, who had been diagnosed with paranoid schizophrenia and had a history of self-harm, died on January 6, 2012, just a day after being released from the Balmoral psychiatric ward at Blackpool Victoria Hospital, an inquest heard.

Speaking after the hearing, her brother Michael Ellis said the family were angry that Lancashire Care NHS Foundation Trust had agreed to Ms Jones’ request to stop having ‘depot’ injections, which had stabilised her condition the previous summer.

He also pointed to an amendment to her care plan which said that their frail mum Joan, who had cancer at the time and has since died, would take responsibility for her daughter’s medication.

Ms Jones, a widow who made arts and crafts for a living, lived at her mum’s home on Canberra Way, Warton, at the time. But Mr Ellis, one of four siblings, said their mum had been in no fit state to take on that responsibility after the inquest heard that the change to the plan may have been an error.

“Vivienne went into hospital to get help, but that help let her down,” he said.

“She was allowed to make a self-diagnosis in coming off her injections, which she had been on for years, and we were not consulted about that. She was a bright, bubbly woman and she was doing fantastic until that point.

“Had that not happened, Vivienne would be here now.”

Mr Ellis said the change in the care plan – which the family had not been party to – was also a mistake.

“Our mum weighed four stone and could not walk, so she was never in a position to take that responsibility for Vivienne’s medication,” he added.

“She was told she had no choice but to have Vivienne back home and we

understand that, on discharge, Vivienne was handed all her tablets.

“Vivienne was let down by the system. We can’t change what’s happened but there has been a catalogue of errors and I hope the trust will learn

lessons so that no other family has to go through this.”

The inquest heard, having come off her injections, Ms Jones was admitted to Blackpool Victoria Hospital following an overdose on December 9, 2011, then transferred to the Balmoral ward, where her behaviour stabilised following medication.

A team of nurses and care co-ordinations were questioned about the decision to discharge Ms Jones at a meeting on January 5, 2012, and about the change to her care plan.

There was agreement that, because her condition had improved, she should not be detained under the Mental Health Act, but would be monitored at home by a crisis team.

But the family disputed evidence that the care plan was altered following a telephone conversation with Ms Jones’s mum.

Inpatient consultant Peter Smith said: “It was a very busy place and it’s very easy for

people to get their wires crossed and for things to slip someone’s mind.

“I do wonder whether that addition to the care plan was a mistake.”

Ms Jones was found unconscious by her mum at home at 8.30am on January 6, 2012. Toxicology tests found extremely high concentrations of quetiapine and metformin in her body.