Staff at a Bexhill nursing home failed to give a dementia patient medication which could have prevented his death because they had run out and took several days to order more.
James Lewsey died on November 11 last year after a stomach ulcer burst, leaving the 72-year-old screaming in agony.
An inquest into Mr Lewsey’s death heard how nursing staff at the Bay House Care Home in Middlesex Road failed to give him vital medication to protect his stomach for a full nine days before he died.
And along with missed doses of painkillers and laxatives, staff had failed to give Mr Lewsey 116 doses of medication in just 34 days.
London-born Mr Lewsey was diagnosed with Parkinson’s in 2003, but continued to work as an electrician until his retirement in 2006.
The inquest heard how, following his retirement, Mr Lewsey and his wife of 30 years Rosalie were ‘inseparable’.
But Mr Lewsey was diagnosed with dementia in 2012 and later moved into Whitebeach Care Home.
Mr Lewsey was happy at the St Leonards home, but suffered a fall and was admitted to the Conquest Hospital on July 29 last year with a fractured pelvis.
He spent 12 weeks in hospital, where it was discovered Mr Lewsey had a benign peptic ulcer.
Doctors at the hospital immediately put him on omeprazole, a drug designed to reduce the amount of acid in the stomach, reducing ulcer irritation and erosion.
Mr Lewsey was finally discharged in October and moved to Bay House Care Home in Bexhill.
But just weeks later, on November 11, he was rushed to hospital by ambulance.
He had aspirated large amounts of blood and vomit and died just hours later.
One nurse, who had given Mr Lewsey his last dose of omeprazole on November 2, said she believed there were more in the cupboard.
However, it took until November 9 for another nurse to fax a request for more medication. When interviewed, she said the fax machine was unreliable and she was unsure it had gotten through. She said she was “too busy” to chase the prescription up.
Two other nurses were aware of the lack of medication but took no action as they thought someone else was dealing with the problem.
Anita Cordell, protection manager at adult social services from East Sussex County Council, said: “There was no clear handover or discussions which meant that they may have run out of the medication.”
She said Bay House was “very cooperative” and carried out a medication audit immediately to ensure other residents were getting the drugs they had been prescribed.
No other problems were found and following an unannounced inspection in the weeks after Mr Lewsey’s death, the Care Quality Commission confirmed there were no further concerns about medication.
Ms Cordell said that management at the home recognised they had “taken their eye off the ball a little bit”.
Pathologist Ian Hawley, who carried out Mr Lewsey’s post-mortem, told the inquest the failure of staff to give Mr Lewsey his omeprazole may have contributed to his death.
Dr Hawley said: “I believe it played some part.
“Omeprazole is protective of the stomach and oesophagus.
“If it is not given, that protection is lost.
“Omeprazole would have helped.”
He added that “on the balance of probabilities” if Mr Lewsey had been given the omeprazole, he may not have died.
Nazir Manji, proprietor of Bay House, said: “I have had Bay House for nine years. This is the first issue that has ever arisen.
“I employ professionals to carry out their duties in line with the code of conduct and regulatory guidelines.
“In this instance I am deeply saddened that this has happened and I feel grossly let down by the professionals I had in my employment.”
Speaking after the hearing, Rosalie Lewsey told the Observer: “We are all devastated to know that Bay House simply said they ran out of drugs which could have kept my husband alive and prevented him dying in agony as he did.
“And, as stated by social services in court, 116 doses of medication were missed in the 34 days he was there, which is quite unbelievable.
“We hope this highlights serious problems and prevents anything similar happening to someone else.
“We can now, of course, pursue further action.”
Coroner Alan Craze recorded a verdict of death from natural causes.