Katherine Hutchinson was the nurse in charge at Whitwell Park Care Home in Derbyshire on October 6, 2010 – the night Fiona Jayne Thorne, a 36-year-old woman with learning difficulties, died. Ms Hutchinson was working at the care home despite Senior Coroner Dr Robert Hunter’s investigation finding “no record of Katherine Hutchinson ever attending a nursing course at Sheffield University or Sheffield Hallam University, or for that matter graduating with any degree or diploma.”
After she delivered the fatal dose, Ms Hutchinson then tried to cover up her mistake, according to Derbyshire Live.
Dr Hunter said that Ms Hutchinson took the patient to bed and left her there until she was “found by the care support worker around midnight, when undertaking routine checks on residents”.
Her mistake was only discovered following an audit of the medication trolley which found that a quantity of clozapine was missing.
Miss Thorne was discovered lying on her bedroom floor in the dark. The alarm was raised and Ms Hutchinson arrived at the room “within 30 seconds”.
However, when she got there she said Ms Thorne had already died.
Chesterfield Coroner’s Court heard that when a patient is found unconscious and unresponsive, the default position, if it was an unexpected death, would have been to begin CPR and call an ambulance.
Ms Hutchinson did neither.
Dr Hunter also heard evidence that Ms Hutchinson, despite being the nurse in charge that evening, “was not qualified to verify death” but “took it upon herself and stated that Ms Thorne had died or was dead”.
Dr Hunter went on to tell the court that after Ms Thorne’s death, the care home “did not of itself initiate any meaningful investigation into the circumstances of Miss Thorne’s death”.
Ann Gibbons, one of the directors of the care home, told the hearing that a suspension of Ms Hutchinson was discussed but she could not give a reason as to why it did not happen – despite the fact that Ms Hutchinson had administered the drug that led to her death.
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Angela Starr, an inspector for Care Quality Commission, made an unannounced inspection of Whitwell Park in February 2011 and found the training records for staff were very poor.
Concluding the inquest Doctor Hunter delivered a narrative verdict, stating that Miss Thorne died as a result of the toxic effects of a “high dose of clozapine, administered by her healthcare professional. The clozapine was not prescribed for Miss Thorne but for another patient.”
Dr Hunter continued: “On the balance of probabilities, the healthcare professional was aware of the error and failed to report it or take any action to seek medical attention for Miss Thorne. The failures to acknowledge the drug maladministration and to seek medical attention were gross failures and as such Miss Thorne’s death was contributed to by neglect.”
Express.co.uk has contacted Whitwell Park Care Home for comment.