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News & Star
By Phil Coleman
Last updated at 11:37, Thursday, 22 August 2013
A former soldier with mental health problems lay dead in his Carlisle home for a month after a series of blunders by his care providers.
An inquest heard how Graham Webster, 60, had distanced himself from his family and was drinking up to a bottle of whisky a day in the months before his death.
At the time, he was under the care of the Cumbrian NHS trust which was working with a local mental health charity to give him a care package.
The court was told of a catalogue of errors, which left Mr Webster on the wrong medication and without the weekly visits from staff that would have led to the discovery of his body.
After hearing evidence of the tragedy, coroner David Roberts said he would write to the Cumbria Partnership NHS Trust, which was supervising Mr Webster’s care, to urge them to more effectively monitor medication changes.
The former soldier had been diagnosed with paranoid schizophrenia, and was diagnosed as alcohol-dependent.
Though given emotional and practical support by his sisters Karen Webster and Jacqueline Steele, he began to distance himself from them and lived alone at a house in Briar Bank, Belah.
His body was found there on March 7 last year after the alarm was raised by a support worker from the Croftlands Trust.
Consultant psychiatrist Dr David Prosser confirmed that in August 2010 he had reviewed Mr Webster, who said he felt less suicidal when he was drinking.
The doctor said that he was concerned that Mr Webster was taking the anti-depressant dothiepin. This can pose a particular risk to patients who are heavy users of alcohol, who face an increased risk of inhaling their stomach contents because their retching reflex can be suppressed.
Dr Prosser faxed instructions to the patient’s Spencer Street surgery asking that the dothiepin be replaced by another anti-depressant.
The inquest heard that the new prescription was only partly acted upon – and not sanctioned by a GP.
Mr Webster was given a medication regime that included a continuing daily dose of dothiepin.
In her evidence, GP Dr Anke Selbman said the surgery had now changed its systems to prevent a repeat of this kind of mistake so that all medication changes would have to be checked by a GP.
Psychiatric nurse Lynne Cooper, employed by the Cumbria Partnership trust, was supervising Mr Webster’s care in the community.
She confirmed she was with him when Dr Prosser agreed to change his medication regime yet she failed to notice that his drugs continued to include a daily dose of dothiepin.
She said she was now more diligent in updating risk assessments and better systems were in place to monitor client visits.
The inquest also heard from Jillian Saunders, deputy chief executive of the Croftlands Trust, whose staff were contracted to carry out the weekly visits to Mr Webster.
On February 7 and 14, care workers called round but got no response.
Administration errors meant no visits were scheduled for February 20 and 27, while a food delivery firm also contacted the charity to say it could not get a response after trying a number of times to get him to answer the door. A worried care worker eventually raised the alarm and police forced entry to Mr Webster’s house on March 7.
“We missed opportunities to identify the problem,” said Mrs Saunders.
Croftlands Trust and the Cumbria Partnership Trust both said that they have now tightened up procedures to ensure a similar tragedy could not be repeated.
A pathologist concluded that Mr Webster died from the combined effects of inhaling the contents of his stomach and dothiepin toxicity.
Recording a verdict that his death was drug-related, Mr Roberts said steps had clearly been taken to prevent a repeat of the situation.
He would now write to Cumbria Partnership NHS Foundation Trust to recommend that checks are made to ensure medication changes ordered by a senior Trust doctor are acted on.