A pharmacy in Slough has sparked concerns with a coroner after a woman died from accidentally taking her husband’s medication.

Sewa Kaur Chadda was found collapsed on the floor of her home in Slough on May 5, 2023. The 82-year-old was taken to Wexham Park Hospital to be treated.

She died five days later May 10 after it emerged that she had been taking her husband’s medication instead of her own.

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An investigation was opened at Berkshire Coroner’s Court from March 27 to May 24 this year.

Her cause of death was ruled an accident but assistant coroner Katy Thorne KC sent out several reports after the death of Mrs Chadda caused her concern.

‘Prevention of Future Death Reports’ are sent by coroners following an inquest to the relevant authorities to prevent future deaths from causes uncovered during the inquest.

The report was sent to the Slough Pharmacy, formerly Lloyds Pharmacy, in Upton Lee Parade, Wexham Road, the Berkshire Integrated Care Board, the contractor support officer for Community Pharmacy England, the chief executive for the Local Pharmacy Commission, the chief executive for the General Pharmaceutical Council, the chief executive for the National Pharmaceutical Association, the NHS Specialist Pharmacy Service and the Medication And Healthcare Products Regulatory Agency.

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During the inquest, it was heard that Mrs Chaddha had been living with her husband in Slough. They both had a number of physical health conditions requiring multiple prescribed medications.

They both had cognitive impairment due to their age.

After Mrs Chadda was found unresponsive at home, it was discovered that she had been taking her husband's medication instead of her own for several days, including diabetes medication.

Her blood sugar levels were found to be extremely low.

She died of hyponatraemia caused by the necessary treatment for hypoglycaemia which was in turn caused by the accidental ingestion of hypoglycaemic medication.

Ms Thorne’s concerns, as outlined during the inquest, were that the medication provided to Mrs Chadda and her husband came weekly in identical dosset boxes, despite both patients being elderly and suffering from cognitive impairment.

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She noted that the only difference between the boxes containing their prescriptions were levels with small types including their names.

Evidence was given at the inquest that there was no guidance or policy in place for pharmacists to follow when issuing medication to patients with cognitive impairments.

Additionally, there was evidence that dosset boxes of different colours or labels with different colours were not routinely given to elderly or cognitively impaired patients living at the same address.