Lancashire Police probed care home death of Preston woman after she died from rare drug overdose, coroner told
An elderly widow who died in a Lancashire care home was found to have traces of a rare barbiturate in her system.
An inquest at Preston Coroner's Court was unable to establish whether Sheila Shuttleworth took it - or was given the drug.
Area coroner Emma Mather recorded a narrative conclusion at a hearing into the death of Mrs Shuttleworth, who died at Meadowfield House care home in Fulwood.
The cause of death was recorded as an overdose.
The icoroner was told toxicology tests revealed traces of phenobarbital, which was not prescribed to her and not kept in the care home.
Ms Mather, who criticised health professionals for "missed opportunities" to help Mrs Shuttleworth with her pain and depression, said it was unclear how she took the barbiturate.
She said: "It is not possible to ascertain where this drug came from.
"It is possible it was self inflicted.
"It is possible that it was consented to.
"It is possible it was not consented to."
Ms Mather apologised to Mrs Shuttleworth's friends for not being able to give them all the answers.
The inquest heard that in January 2025 the 87-year-old widow was taken to Royal Preston Hospital with a broken femur. Whilst in hospital she complained of being in a lot of pain and at one point attempted to harm herself.
She was referred to mental health services and then discharged to Meadowfield House with a view to being rehabilitated and returned to her home.
Friends said her mood was low and she was in pain. She kept asking for more medication.
Carmel Jones, associate director of nursing in Lancashire, said a thorough review of the care given to Mrs Shuttleworth by four teams was carried out.
After her transfer to the care home, there was no further contact with mental health services. They rang her mobile while she was in the care home, which went unanswered.
Mrs Shuttleworth received eight visits from district nurses and was given medication. But no care plan was put in place.
Ms Mather asked: "Why not?"
Ms Jones said there was no explanation for that in the notes.
"That 's not very good is it?" replied Ms Mather.
The coroner added that there appeared to be a breakdown in communication between mental health services and district nurses.
There was also no handover when Mrs Shuttleworth was taken to the care home.
The coroner said it felt like Mrs Shuttleworth was "left behind".
Ms Jones said changes had been made to working practices since Mrs Shuttleworth's death.
Emma Alexander, operations manager for Lancashire County Council, said the care home did not know about Mrs Shuttleworth's attempt to self harm in hospital.
She said Mrs Shuttleworth was prescribed medication for her pain and this was administered by staff at the home. All medication was kept in a locker and there was a full record kept.
Ms Alexander said staff never gave Mrs Shuttleworth anything to help her sleep.
The inquest was told that when Mrs Shuttleworth was found dead at the home in February, she was clutching a packet of paracetamol. It was assumed it was a medication overdose. She also had heart disease and was frail.
Then 10 weeks later toxicology tests showed the presence of phenobarbital.
Det Insp Paul Price said the drug was not common in the UK.
Inquiries were made to see if there had been any similar incidents at the care home and there were none.
Asked if he could clarify where the barbiturate came from, he said: "No. It has been frustrating."
Coroner Ms Mather said there had been a "lack of professional curiosity" by health professionals over Mrs Shuttleworth. No real efforts had been made to ease her pain.
She added that proper treatment may not have altered the outcome, but it would have reduced Mrs Shuttleworth's pain.