AN assistant coroner has demanded action after finding that an elderly woman’s death was “exacerbated” by high levels of sedation and immobility in the months before she passed away.

The flaws in the care Miriam Tighe received at Edge Hill Residential Home in Oldham Road, Royton, from e psychiatrist working in the Memory Clinic – part of Pennine Care NHS Foundation – and Royton and Crompton Family Practice “worsened her underlying frailty”, said assistant coroner Rachel Galloway.

Mrs Tighe became a resident at Edge Hill in August, 2016. In October she was experiencing episodes of aggression and agitation and various medications were prescribed by GPs and the psychiatrist to address her symptoms.

However, she continued to receive promazine medication after the psychiatrist had advised that it be stopped, on November 16, 2016 and again on December 16, 2016.

“From November, 2016, Mrs Tighe was regularly over sedated, leading to increased immobility and deconditioning,” said Mrs Galloway.

“In turn, this contributed to and worsened Miriam Tighe’s underlying frailty.”

She said that on December 30, 2016, Mrs Tighe was sedated with promazine and after consultation with the GP an ambulance was called and she was taken to the Royal Oldham Hospital.

Mrs Galloway went on: “The home manager refused to accept Miriam Tighe back at the home on the basis that an EMI (elderly mentally ill) nursing bed was required. Mrs Tighe was admitted to hospital while a bed was found.

On February 6, 2017, she was discharged into the care of Kings Park Residential Home in Ashton. On February 19, 2017, she was admitted to Tameside Hospital, where she received palliative care until she passed away on February 28, 2017.

Mrs Galloway said that during the course of the inquest into Mrs Tighe’s death, the evidence revealed matters giving rise to concern.

“In my opinion there is a risk that future deaths will occur unless action is taken,” she said.

She pointed specifically to the continued administering of promazine against the advice of the psychiatrist and under the control of the manager at Edge Hill Residential Home.

“I found that Miriam Tighe had been over-sedated during her time as a resident at Edge Hill,” she went on.

“It was clear the GPs and the psychiatrist were not aware of decisions being made by each other in October to December, 2016, which led to unsafe prescribing of sedatives and anti-psychotic medication.”

Her report has been sent to Edge Hill, Royton and Crompton Family Practice, Pennine Care NHS Foundation Trust and Oldham Clinical Commissioning Group.

Mrs Galloway said: “In my opinion action should be taken to prevent future deaths and I believe you (the organisations mentioned) have the power to take such action."

The organisations were given 56 days to respond to her report, the deadline for which expired on August 29, although she had the power to extend the period.

She added: “Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.”

Edge Hill Residential Home has been contacted by The Oldham Times but has declined to comment.

A spokesperson for NHS Oldham Clinical Commissioning Group said: “The findings from the coroner’s report for this case have been received by the CCG, and will be reviewed to ensure that any improvements are made within local services as needed.”