What happened
John Collinson, known as Ricky, was 88 and had lived at Kinmel Lodge in Kinmel Bay, Conwy, for about two years after developing dementia. He had been started on a low dose of risperidone in January 2022 to calm agitation. Before the error he was mobile and active; his family described him dancing at the late Queen’s jubilee weeks earlier.
His medication was changed from tablets to liquid. Between 1 and 4 July 2022 he was given 2.5 ml twice a day instead of the prescribed 0.25 ml, ten times the dose. The miscalculation came with the formulation change, and the syringe supplied had unclear measurements.
His son noticed on 1 July that something was wrong and was told nothing was amiss. A manager realised days later.
The outcome
Afterwards he was increasingly sedated and immobile and never returned to his previous level of activity. Largely confined to bed, he developed a pressure sore on his heel. He was moved to another home in Colwyn Bay, then to hospital, where he died on 30 August 2022 of bilateral pulmonary emboli following a deep vein thrombosis.
An inquest at Ruthin concluded on 30 June 2025. The coroner, John Gittins, found the medication error “more than minimally” contributed to the death.
The home contacted the GP as soon as the error was identified and stopped the medication, and has since introduced a digital system for medicines management. No prosecution or regulatory outcome is recorded.
What went wrong
Nobody checked the calculation against the prescription. The syringe markings were unclear, and this resident was among the first at the home to receive the medicine in liquid form.
The error ran for four days, twice a day, before the home recognised it. The home was told by a family member that something was wrong, and the first answer was that nothing was.
The consequence was not only sedation. A man who had been dancing was bedbound within days, and immobility produced the clot that killed him.
What it teaches
Antipsychotic prescribing for agitation is chemical restraint. It is quieter than a hold, recorded in a medicines chart rather than an incident form, and carries a dosing error risk on top of the sedation risk.
A change of formulation is the moment to check the arithmetic twice, with a second pair of eyes and a written record of what was given. The coroner’s finding is not that the drug was the wrong choice. It is that the arithmetic went unchecked for four days.
Sedation that removes a person’s mobility is a clinical event, not a quiet resident, and sudden immobility should trigger the same response as a fall.
Questions for the room
- The dose was ten times too high for four days. What check would have caught it?
- You are the manager told the syringe markings are unclear. What do you do before the next round?
- A family member says something is wrong and is told nothing is. What has to change?
Evidence and limits
Confidence: probable. The account rests on one publisher’s report of the inquest, with an earlier report of the family’s account. Both are BBC News and count as one source. No prevention of future deaths report was located.
The reports differ on how long the error ran, four days in one and a week in the other; this page uses the coroner’s dates, 1 to 4 July 2022.
Collinson is named because the reporting names him. No member of staff is named and no finding is made about any individual.
Our physical interventions training covers restraint and the monitoring that has to go with it, including the sedation that follows.
Sources
- BBC News, 30 June 2025 · Care home resident died after medication overdose
- BBC News, 2 August 2023 · Conwy care home overdosed man, 88, claim family
Reviewed 20 October 2026.