The mother of a woman who died when she was given the wrong drug by an unqualified nurse has spoken of the loss of her daughter and her subsequent fight for justice that has lasted over a decade.
Lesley Hall’s vulnerable daughter Fiona Thorne died at the Whitwell Park Care Home in Derbyshire when she was given powerful medication intended for another resident. When unqualified nurse Katherine Hutchinson realised her mistake, she tried to cover it up, the inquest into Miss Thorne’s death heard.
It has taken more than 11 years for Mrs Hall to get answers about the night her beloved daughter died. She says that her long wait for answers has been a nightmare that has taken its toll on her health.
Mrs Hall said: “You think it’s a nightmare and it doesn’t happen to us but it did. I went to my dentist and found out I’d been grinding my teeth in the night due to the stress and worry of it all, I’ve had therapy to try and relax me.
“I’ve had various operations on my guts because of the stress of it all, I’ve had sleepless nights. I look alright on the outside but on the inside, it’s taken its toll because of this.”
Miss Thorne, 36, who learning and behavioural problems, spent the day she died with her father, brother and sister, with them telling her mother that they’d had a “lovely day”. Only a few hours later, Miss Thorne was found on the floor of her bedroom having been given powerful anti-psychotic drugs meant for another patient.
At an inquest hearing at Chesterfield Coroners Court, it was determined that the nurse on duty that night back in 2010, Katherine Hutchinson, had given Miss Thorne clozapine, and then tried to cover up that fact, despite knowing what she’d done. She then took Miss Thorne to bed and left her there. She never reported her mistake, beginning a catalogue of errors both before and after Miss Thorne’s death.
Mrs Hall, said: “To date, myself and the family, feel totally dismayed and disgusted at the incompetence and apparent apathy by so-called professional institutions.”
She has pointed to numerous errors made by the people running the care home – prior to Miss Thorne’s death in October 2010 – in the recruitment of Katherine Hutchinson, arguing that she was employed as a night duty nurse, despite, according to the inquest, falsely claiming she had a nursing degree from the University of Sheffield and that she was registered with the Nursing and Midwifery Council. Neither Sheffield University nor the NMC had any record of her being registered with them.
The inquest also uncovered major failings in the training of Ms Hutchinson, including the lack of the qualification needed to administer medication to residents, despite Ms Hutchinson, who has since retired from the care profession, doing so on a regular basis before and after Miss Thorne’s death. The care home is now under different ownership
In a statement to Derbyshire Live, a spokesperson for the care home said: “Whitwell Park Care Home wishes to express its condolences to the family and friends of Fiona Jayne Thorne. She died on 7 October 2010. Whitwell Park Care Home is now under new ownership.
“Our latest Care Quality Commission report rated the home as ‘Good’. At the inquest the Coroner was satisfied that there was a very low risk of such an incident happening again as there are enough checks and balances currently in place at the Home.”
Mrs Hall has also spoken of the problems she faced with Derbyshire police when they began investigating her daughter’s death. She claimed that the police didn’t attend the care home on the night of Miss Thorne’s death and a transcript of a telephone call from the police to the care home has the officer recorded as saying “you’re not expecting the police to come round are you?”.
Mrs Hall says that statement was “mysteriously missing when initially investigated by the serious crime police officers”. However her family made them aware of it from the original transcript.
“I feel let down totally from the police and I’ve put in an official complaint. From the night Fiona died we were let down because the police should’ve attended. She was 36-years-old she was fine, she was fit and then she was found two hours later.
“Had the police turned out to the home on the night Fiona died, this would’ve probably been put to bed over two years, not nearly 12. We were told they would’ve gone down a different route but because they didn’t turn out this is why it’s dragged on as long.”
Over the course of more than a decade, the family has made five appearances at Coroners Court with numerous delays, including the ill health of the Senior Coroner Doctor Robert Hunter, forcing it to be delayed on numerous occasions.
During the first hearing in November 2012, Dr Hunter heard evidence that Miss Thorne had ingested an excessive amount of the drug that killed her. He adjourned the hearing and ordered the police to report the findings to the Crown Prosecution Service (CPS). However at the next hearing in December 2013, Dr Hunter was told his instruction to alert the CPS hadn’t been carried out, forcing another delay to the hearing.
Responding to the claims made by Mrs Hall, Deputy Chief Constable, Kate Meynell, from Derbyshire police said: “Firstly, I would like to express my sincere condolences to Fiona’s family and all those affected by her death. Following the initial response to Fiona’s death, a review was conducted by the regional major crime team, which was far reaching, proportionate and thorough, however, ultimately no charges were brought.
“Fiona’s family submitted a complaint to the force following her death with reference to the initial police response and investigation. This complaint was reviewed by our Professional Standards department at the time and was not upheld.
“However, following the outcome of the inquest into Fiona’s death, a review of the complaint decision has been launched and we will ensure that, where appropriate, actions are taken to address any issues which may come to light. Fiona’s family have been made aware of the decision to review this complaint outcome and we will remain in close contact with them for the duration of this investigation.
“In the years since Fiona died, some of our processes have already changed, for example our protocol for attendance of sudden deaths. Formerly the decision to attend was taken by a Sergeant, however this is now the responsibility of our Force Incident Manager who is of Inspector rank.”
In his conclusion, Dr Hunter said “gross failures” and “neglect” at Whitwell Park Care Home, back in 2010, contributed to Miss Thorne’s death but despite that, Mrs Hall says she doesn’t want anything to happen to the care home as it is now: “We’d no idea what was happening at that home but I didn’t want that home to be punished for that one person’s mistake.
“I’m so happy that the home has been taken over and we had the new homes’ barrister giving evidence that it’s not the same home and it’s running as it should and I actually said to the coroner if there’s one lesson to be learned by Fiona’s death it’s that.
“Maybe now I’ll start sleeping at night instead of waking up having nightmares about my daughter and what happened to her. I’m just glad that the coroner put my mind at rest, knowing that the medication she was given shut her body down without her being in pain and that she went to sleep.”
Derbyshire Live also contacted the Crown Prosecution Service regarding the death of Ms Thorne. In a statement, a spokesperson said: “Evidence relating to Miss Thorne’s death was presented to the CPS in 2016 and a conclusion reached that there was insufficient evidence to consider criminal proceedings.”