Can Overprescribing Medication Cause a Fatal Fall? Polypharmacy, Elderly Patients and Medication Reviews

Taking several different medicines does not necessarily mean that an elderly patient has been overprescribed. For many people living with several medical conditions, multiple medicines are both necessary and beneficial.

The difficulty arises when nobody appears to stand back and ask a deceptively simple question: does this patient still need all of these medicines, at these doses, in this particular combination?

That question becomes especially important when an older person begins suffering dizziness, weakness, confusion, collapses or repeated falls.

Recent reports have again highlighted concerns about polypharmacy – the use of multiple medicines at the same time – and whether potentially harmful combinations of medication are always identified quickly enough.

For some families, the consequences can be devastating. An elderly person may fall, suffer a serious fracture, deteriorate during a prolonged hospital admission and ultimately die.

This raises an important medical and legal question: could medication have contributed to the fall and, if so, should something have been done about it earlier?

What is polypharmacy?

Polypharmacy generally describes a person taking multiple medicines at the same time.

It is important not to confuse polypharmacy with negligent prescribing. An elderly patient with heart disease, high blood pressure, diabetes and other long-term conditions may quite properly require several different medicines.

The concern is problematic polypharmacy.

NHS England describes problematic polypharmacy as including circumstances where the potential harm from a person’s medicines outweighs their benefits, where medicines are no longer clinically appropriate or where a combination of medicines is causing, or has the potential to cause, harm.

Problems can arise where:

• a medicine is no longer necessary;
• the dose has become inappropriate as the patient has aged;
• kidney or liver function has changed;
• two or more medicines interact;
• medication contributes to dizziness or low blood pressure;
• another medicine is prescribed to deal with what is actually a side-effect of an existing drug;
• warning symptoms are repeatedly reported without the medication being reconsidered; or
• repeat prescriptions continue without an adequate clinical review.

The number of tablets alone is therefore not the decisive issue. What matters is whether the patient’s complete medication regime remains necessary, appropriate and safe.

Why can medication increase the risk of falls in elderly patients?

Ageing can alter the way in which the body responds to medicines.

A drug which a patient tolerated successfully for many years may affect them differently later in life, particularly if their general health has deteriorated or several other medicines have subsequently been introduced.

Certain medicines can contribute to symptoms including:

• dizziness;
• drowsiness;
• confusion;
• weakness;
• low blood pressure;
• postural hypotension;
• dehydration; and
• impaired balance.

Any of these may potentially contribute to a fall.

The current NICE guidance on falls in older people recognises medication as an important consideration when assessing and preventing falls.

NICE’s supporting evidence also specifically discusses how medicines such as antihypertensive drugs can contribute to falls through dizziness or light-headedness and recognises that interactions between medicines can affect an individual’s risk.

This is important because an elderly person’s fall should not automatically be dismissed as simply an inevitable consequence of getting older.

Should medication be reviewed after an elderly person falls?

A fall can have many causes.

Poor eyesight, muscle weakness, environmental hazards, neurological disease, cardiovascular problems and impaired balance are just some possibilities. Medication is another.

Where somebody taking several medicines develops recurrent dizziness, collapses or falls, their treatment may therefore require careful reconsideration.

NICE’s medicines optimisation guidance provides guidance on medication reviews and the safe and effective use of medicines.

NHS England’s Structured Medication Review programme also specifically identifies people with complex and problematic polypharmacy, including people taking ten or more medicines, amongst those who may benefit from a structured medication review.

A proper review should involve considerably more than simply confirming the names of the tablets on a repeat prescription.

Questions may include:

Why was each medicine originally prescribed?

Is it still necessary?

Is the dosage still appropriate for this particular patient?

Has the patient’s kidney or liver function changed?

Could one medicine be interacting with another?

Has the patient developed dizziness, weakness or confusion?

Have there been previous falls?

Were blood tests, blood-pressure checks or other monitoring undertaken when required?

Has anybody considered whether a medicine should be reduced, changed or stopped?

These questions can become particularly important where relatives say that they repeatedly raised concerns about a person’s deterioration.

Blood-pressure medication, dizziness and falls

Blood-pressure medication provides a useful example of why individualised medication reviews can matter.

Medicines used to treat hypertension can provide considerable benefits, including reducing the risk of cardiovascular disease. Their use does not become inappropriate simply because somebody subsequently falls.

But treatment still has to remain suitable for the individual patient.

Blood-pressure lowering medicines can sometimes contribute to dizziness or light-headedness. For an older person who becomes dizzy when standing up from a chair or getting out of bed, the consequences can be serious.

A fall that might result in relatively minor injury to a younger adult can cause a hip fracture, serious arm fracture or head injury in an older and frailer patient.

The correct question is therefore not simply “Was this medicine capable of causing dizziness?”

The investigation should ask whether this particular patient’s symptoms, medical history, dosage, other medicines and previous falls should reasonably have resulted in a review or alteration of treatment.

What if several medicines interact?

Sometimes the problem is not one obviously inappropriate prescription.

It is the combination.

One medicine may reduce blood pressure. Another may have a diuretic effect. Another may contribute to drowsiness. Individually, there may be a perfectly reasonable clinical justification for each drug.

The cumulative effect upon an elderly or frail patient, however, can be different.

This is precisely why NHS England describes a Structured Medication Review as a comprehensive review taking account of all aspects of a patient’s health and the balance between the benefits and risks of their medicines.

It is also why an investigation into a suspected medication-related death should not necessarily concentrate only upon the final prescription issued before the patient’s deterioration.

The relevant prescribing history may extend back months or even years.

What is a prescribing cascade?

Another potential problem is a prescribing cascade.

This can happen when the side-effect of one medicine is mistaken for a new medical condition. Instead of recognising the original medicine as the possible cause, another medicine is prescribed to treat the new symptoms.

The second medicine can then cause further side-effects, potentially resulting in an increasingly complicated medication regime.

A prescribing cascade is not automatically negligent. There may be sound clinical reasons for introducing additional treatment.

However, where an elderly patient’s condition deteriorates as the number of medicines increases, it may be necessary to investigate whether the overall medication regime was properly reviewed.

For more information about prescription errors, dangerous combinations of drugs and failures to monitor treatment, see R James Hutcheon Solicitors’ specialist guide to medication error claims and wrong prescription compensation.

When could overprescribing amount to medical negligence?

The fact that medication caused a side-effect does not automatically mean that somebody was negligent.

Almost all effective medicines have potential risks and side-effects. A patient can suffer a recognised adverse reaction despite receiving entirely appropriate medical care.

For a clinical negligence claim in England and Wales, it will generally be necessary to establish both breach of duty and causation.

There would need to be evidence that the care fell below the appropriate professional standard. Depending upon the circumstances, that might involve an unreasonable failure to:

• review long-term medication;
• react to repeated falls;
• investigate dizziness or hypotension;
• recognise a significant drug interaction;
• adjust medication following changes in health;
• undertake appropriate blood tests or other monitoring;
• communicate medication changes between hospital and primary care; or
• act upon repeated concerns raised by the patient or family.

That is only the first part of the investigation.

It must then be established that the failure actually made a difference to the outcome.

The crucial question: did the medication cause the fall?

Causation can be particularly complicated in cases involving elderly patients.

Imagine an elderly patient taking numerous medicines who begins experiencing dizziness. They fall and fracture their hip. They are admitted to hospital, become increasingly immobile and subsequently develop serious complications before dying several weeks later.

The investigation cannot necessarily stop at the immediate medical cause of death.

It may be necessary to examine the complete sequence:

Medication or drug interaction → dizziness/hypotension → fall → fracture → hospitalisation → complications → death.

Independent medical evidence would ordinarily be required to determine whether the medication probably caused or materially contributed to the fall and whether different treatment would probably have avoided the eventual outcome.

Age and pre-existing illness do not themselves prevent a claim.

Equally, the fact that an elderly patient died following a fall does not establish that their medicines were responsible.

The medical records, chronology and independent expert evidence become critical.

Could a fatal fall result in a compensation claim?

Potentially.

Where negligent prescribing, overprescribing, inadequate monitoring or an unreasonable failure to review medication causes a fall which ultimately contributes to someone’s death, the circumstances may justify investigation as a fatal medical negligence claim.

Claims following a death can be legally more complicated than ordinary personal injury claims because different rights can arise on behalf of the deceased’s estate and their dependants.

Our specialist guide explains more about fatal medical negligence claims and how compensation following a death may be investigated.

Where the patient survives but suffers an injury following an incorrect prescription, dangerous drug combination, inappropriate dosage or failure to review treatment, our associated specialist solicitors at R James Hutcheon Solicitors provide further information about medication error compensation claims.

What evidence should families preserve?

Where relatives are concerned that medication may have contributed to a loved one’s fall and subsequent death, it is important to establish a detailed chronology.

Relevant evidence can include:

• GP records;
• repeat prescription records;
• pharmacy records;
• hospital records;
• structured medication review records;
• blood-test results;
• blood-pressure readings;
• records of earlier falls;
• ambulance records;
• hospital discharge summaries;
• correspondence between specialists and the GP;
• the death certificate;
• post-mortem evidence; and
• documentation from a coroner’s investigation or inquest.

It can also be important to establish what the family reported and when.

For example, relatives may have repeatedly reported that a patient had become dizzy, confused or unstable on their feet.

If there were several falls but no meaningful reconsideration of medication, that history could become relevant when independent experts consider whether the patient’s treatment was reasonable.

What about repeat prescriptions?

Repeat prescriptions are convenient and essential for millions of patients.

But medication should not simply continue indefinitely because it appeared on the previous prescription.

As people’s health changes, treatment that was entirely appropriate five or ten years earlier may require reconsideration.

This is particularly relevant for elderly patients who have accumulated additional medicines from different clinicians.

The GP may prescribe one medicine. A hospital consultant introduces another. A different specialist recommends something else. A hospital admission results in further changes.

Unless somebody considers the whole medication picture, potentially significant interactions or unnecessary medicines may be overlooked.

That is one reason why the NICE medicines optimisation guidance places importance upon medication review and communication when patients move between different healthcare settings.

Can a GP be liable for failing to review medication?

Potentially, although the absence of a medication review does not automatically establish negligence.

The legal question is whether the care provided fell below the standard reasonably expected in the circumstances.

Relevant considerations could include:

• the patient’s age and frailty;
• the number of medicines being taken;
• known risks associated with those medicines;
• previous adverse reactions;
• repeated falls or collapses;
• reports of dizziness or confusion;
• blood-pressure readings;
• kidney and liver function;
• recommendations made by hospital clinicians;
• whether appropriate monitoring occurred; and
• what would probably have happened following an appropriate review.

A claimant would still have to establish that the failure caused or materially contributed to injury.

Could a hospital also be responsible?

Yes.

Medication management frequently crosses the boundary between primary and secondary care.

A hospital may stop one medicine, alter another and introduce a third. Those changes then need to be communicated accurately to the GP, pharmacy, care home and patient.

Errors can potentially occur when a patient is admitted to hospital, transferred between wards or discharged home.

The issue is sometimes referred to as medication reconciliation – establishing an accurate and current record of everything the patient should be taking.

Where responsibility is unclear, a solicitor investigating the claim may need to obtain records from several healthcare organisations rather than assuming that the GP, hospital or pharmacist was solely responsible.

Repeated falls should not simply be dismissed as old age

One of the most important points is that repeated falls should not automatically be regarded as an unavoidable consequence of getting older.

There are numerous possible causes, and medication is only one of them.

However, where an elderly person taking multiple medicines begins experiencing:

• unexplained dizziness;
• weakness;
• confusion;
• recurrent falls;
• collapses;
• dehydration;
• very low blood pressure; or
• a marked deterioration following changes to medication,

their complete medication regime may warrant careful clinical review.

Families understandably place considerable trust in doctors, pharmacists and other healthcare professionals to recognise when a previously appropriate medicine may no longer be appropriate.

Where those warning signs are missed and a patient suffers serious injury or dies, it may be necessary to investigate whether earlier intervention would probably have changed the outcome.

Fatal medication error and overprescribing claims

Fatal medication cases can involve difficult questions of both medicine and law.

The investigation may need to determine not merely whether a particular drug was capable of causing dizziness or a fall, but whether it probably did so in that individual patient and whether a reasonably competent clinician should have acted differently.

R James Hutcheon Solicitors has experience investigating medication errors and serious medical negligence claims. You can read our comprehensive guide to medication error claims, including wrong prescriptions, inappropriate dosages, drug interactions and failures to monitor treatment.

For cases where the patient has died, further information is available in our specialist guide to fatal medical negligence compensation claims.

Anyone who believes a relative’s medication contributed to a fatal fall should obtain specialist advice as early as possible. Medical records, prescribing histories and evidence concerning earlier falls can be important when determining whether there is sufficient evidence to investigate a claim.

Important: Patients should never stop, reduce or alter prescribed medication because of information they have read online. Concerns about medicines should be discussed with a GP, pharmacist or other appropriate healthcare professional.

This article provides general information about the law in England and Wales and is not a substitute for individual legal or medical advice.