Thompson Elliott

I am David Place, His Majesty’s Senior Coroner for the City of Sunderland

On 27th January 2025 I commenced an Investigation into the death of Mr Thompson  Elliott, who died in Sunderland Royal Hospital, Sunderland on 24 th January 2025 aged 83 years. The Investigation concluded at the end of the Inquest on 9 th October 2025. I gave a narrative conclusion ‘From respiratory failure having contracted influenza A whilst in hospital having been successfully treated for an overdose of his opioid  medication.’ The medical cause of death was: Ia Respiratory Failure secondary to Influenza II Metastatic Lung Cancer

Thompson Elliott became a resident at a care home on 6 th December 2024. Mr Elliott was  admitted to Sunderland Royal Hospital on 12 th December 2024 with chest pains. He was  discharged back to his care home on 18 th December 2024 with new analgesia medication.  On 20th December 2024 Mr Elliott was given a combination of his old and new opioid  medication due to uncertainty in the care home as to which applied, as his discharge letter  could not be located. Mr Elliott was then readmitted to Sunderland Royal Hospital due to  the opioid overdose. Whilst in hospital he contracted influenza A having been successfully treated for the opioid overdose, but he did not have the physiological reserves to fight the  virus due to his frailty and underlying malignancy.

During the course of the Inquest the evidence revealed a matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the  circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are: The evidence has revealed significant concerns with regard to the recording and  administration of medication, when patients return to the care home, and a discharge letter cannot be located following a period in hospital. I am concerned that the evidence was that if a patient returned to the care home with new  medication prescribed whilst in hospital to replace previously prescribed medication, and  the patient’s discharge letter could not be immediately located, there would be uncertainty amongst staff as to the correct procedure to follow in such circumstances. Medication that had been stopped whilst in hospital due to its impact upon the patient’s  kidneys continued to be administered on 18 th and 19 th December 2024, before it could be clarified with either the hospital or GP which was the correct medication. The new  medication was not administered on either of those days. The evidence revealed that the new medication was not immediately recorded onto the patient’s electronic medication record (EMAR) and held in a cupboard pending  clarification. Despite no clarification and following a 24-hour delay, it was then  incorrectly added to the record as new and additional medication – not replacement  medication. The medication had been changed to oxycodone due to the impact oramorph was having  upon the patient’s kidneys. Due to the administration error in recording oxycodone as new and therefore additional medication, the patient was then given both oramorph and the new oxycodone medication on the morning and afternoon of 20 th December 2024 which  was 2 days following his discharge. This resulted in an opioid overdose. I am concerned that the evidence was such that it was not possible to determine exactly  what efforts, if any, were made by staff to clarify the medication position with the hospital on either 18 th , 19 th or 20 th December 2024 but medication continued to be administered.  On 21 st December 2024 a team leader was able to speak to the hospital and despite being  advised that if there was no discharge letter to take all medications and clarify the position with the GP, a decision was made to only administer the old medication of oramorph and  there no attempts to contact the GP. There were no attempts to contact 111 or Recovery at  Home for advice. I am concerned that the evidence revealed that there was no policy or guidance document setting out the procedures, which staff must follow in such circumstances, which created  confusion and inconsistent decision making resulting in a medication overdose and  continued use of a medication that had been stopped in hospital due to the harm it was  causing to the patient’s kidneys. The evidence raises a further concern that the procedure still remains unclear despite internal reviews following the death. I shall be glad to be told of any learning arising from this death and timescales and results of your review.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.