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Medication Error Linked to Patient's Death
6 Mar
Summary
- Coroner rules human error in medication dosage significantly contributed to patient's death.
- The patient, Declan Horton, died from aspiration pneumonia and epileptic seizures.
- Hospital implemented system changes following the tragic incident and death.

A coroner has concluded that a significant factor in the death of 27-year-old Declan Horton was human error related to his medication dosage. Horton, who had learning disabilities and cerebral palsy, passed away at Great Western Hospital (GWH) in Swindon on February 6, 2022.
The cause of death was determined to be aspiration pneumonia and epileptic seizures. However, the assistant coroner for Wiltshire and Swindon stated that the reduction in Horton's epilepsy medication played a considerable role in his death.
Horton was admitted to GWH on January 19, 2022, following multiple seizures. His medication dosage was reduced, leading to his discharge on January 26, 2022. Concerns were raised by his family and care home staff about the early discharge and the lowered medication levels.
He was readmitted on January 31, 2022, due to ongoing seizures. His family expressed worries about his care, including feeding routines and delays in diagnostic procedures. In response to the incident, GWH has implemented changes to its medication recording systems and IT protocols.




