A pensioner died after mistaking her husband’s nearly “identical” box of medication for her own.

       A coroner issued a warning to the NHS after Sewa Chaddha, 82, accidentally ingested her husband’s drugs.

       The couple suffered a number of health conditions, as well as “cognitive impairments”, for which they required several prescribed medicines.

       Their prescription boxes were “identical” to each other aside from a small label with their names, which led to Mrs Chaddha accidentally ingesting her husband’s, an inquest heard. She died after days of mistakenly taking his diabetes medication.

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       Katy Thorne KC, the coroner, issued a report to pharmacy organisations across the country to address how there is “no guidance or policy” to follow when issuing medication to patients with cognitive impairments.

       Ms Thorne suggested that different coloured boxes should be used.

       The inquest into the death of Mrs Chaddha, who lived with her husband in Slough, Berks, heard that she was found “collapsed” on the floor at home on May 5

       “It was discovered that she had been taking her husband’s medication instead of her own for several days, including diabetes medication,” the coroner said.

       Death gives way to ‘matters of concern’

       The inquest heard the pensioner’s blood sugar levels were found to be “extremely low”.

       Mrs Chaddha was taken to the nearby Wexham Park Hospital, where she died as a result of ‘accidental ingestion of hypoglycaemic medication’.

       The coroner concluded that while her death was “accidental”, it gave way to several “matters of concern”.

       Ms Thorne, the assistant coroner for Berkshire, said Lloyds Pharmacy provided medication to the elderly couple who suffered a “cognitive impairment”.

       “The two patients’ dosset boxes were identical to each other except for a small pharmacist’s label with small type with the relevant patient’s name,” the coroner said.

       “Mrs Chaddha used one of Mr Chaddha’s dosset boxes, rather than her own, for several days.

       “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, or if there was, it was not well disseminated among the pharmacist population.

       “Evidence was given at the inquest 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.”

       The coroner sent the report to organisations including Slough Pharmacy, Berkshire Integrated Care Board, the Local Pharmacy Commission, the National Pharmaceutical Association and the NHS Specialist Pharmacy Service.