A nurse with no qualifications gave a care home resident a fatal dose of the wrong drug, leading to her death before she then tried to cover up her mistake.
Katherine Hutchinson gave Fiona Jayne Thorne a fatal overdose of a powerful anti-psychotic drug, which was meant for another patient, an inquest heard.
She then tried to cover up her errors which contributed to the death of the 36-year-old with learning difficulties, Derbyshire Live reported .
Ms Hutchinson had, at the time, been the nurse in charge at Whitwell Park Care Home, in Whitwell, Derbyshire despite not having any qualifications.
She gave Miss Thorne clozapine, which had been intended for another resident, on October 6, 2010.
Instead of owning up to what she did, Ms Hutchinson then tried to cover up her mistake by taking Miss Thorne to bed and leaving her there until she was discovered, Senior Coroner Dr Robert Hunter said.
Miss Thorne was "found by the care support worker around midnight, when undertaking routine checks on residents”, the inquest heard.
And then Ms Hutchinson’s mistake was only discovered after an audit was carried out of the medication trolley and a dosage of clozapine was found.
Upon the discovery of Miss Thorne by a care support worker, the alarm was raised and Ms Hutchinson arrived “within 30 seconds”.
However, when she got there, she said that Miss Thorne had already died and no CPR was carried out and an ambulance wasn’t called, completely contrary to care home rules.
Chesterfield Coroner’s Court was told how the care home’s response when a patient is found unconscious and unresponsive is to begin CPR and call an ambulance.
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 Miss Thorne had died or was dead".
He also told the court that after Miss Thorne’s death, the care home "did not of itself initiate any meaningful investigation into the circumstances of Miss Thorne's death".
Even though Ms Hutchinson mistakenly administered the drug that led to Miss Thorne’s death, she wasn’t suspended from duty.
Ann Gibbons, one of the care homes directors, said a suspension was discussed but could not give a reason as to why it didn’t happen.
This meant that Ms Hutchinson was left in charge of residents and responsible for their care and safety following Miss Thorne’s death.
This “continued to place other residents at risk of harm and danger”.
In his summary, Dr Hunter said: "Either the directors and management of Whitwell Park failed to appreciate the significance of the circumstances in which Miss Thorne came by her death or they chose to bury their heads in the sand, rather than being proactive in investigating and taking appropriate action in relation to Katherine Hutchinson."
When confronted with the fact Ms Hutchinson had no qualifications, Dr Hunter said: "We heard that Katherine Hutchinson alleged to have a degree in nursing from Sheffield University.
“My investigations both at Sheffield University and Sheffield Hallam University found no record of Katherine Hutchinson ever attending a nursing course there or for that matter graduating with any degree or diploma."
Ms Hutchinson began working at the care home in September 2009, but did not have her induction marked off until May 2010.
Whilst Mary Marsh, the registered manager of Whitwell Park, said that she had assessed Ms Hutchinson twice on the administration of medication, no paperwork was submitted to show she had been signed off as competent.
On top of that, any training for Ms Hutchinson was shown to have only been documented after Miss Thorne’s death.
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. In particular, Katherine Hutchinson's training records were poor.
Delivering their verdict, Dr Hunter said: "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."
Whitwell Park Care Home has been approached for comment.
