There is a “lack of clarity” around the roles and responsibilities of pharmacy workers who attend patients’ homes, a coroner has warned in a report on the death of an elderly man who suffered a fall at home.

Edward Steele, an assistant coroner in East Riding of Yorkshire and Kington-Upon-Hull, sent a prevention of future deaths report to the General Pharmaceutical Council and Orchard 2000 Pharmacy in Hull last Monday (July 10) concerning the death of Harold Wilberforce on January 28 this year at the age of 87.

Mr Wilberforce, who suffered from COPD and dementia, fell on January 16 and was subsequently found by an “employee from a pharmacy delivery centre” who helped him get into a chair. He complained of a leg injury and resisted the delivery agent’s efforts to call an ambulance.

She left a note explaining that he had had a fall and left the premises without a call being made to the emergency services.

Mr Wilberforce suffered a further fall and was discovered by his neighbour “much later the same evening” according to the report. Having suffered a broken hip, he was taken to hospital, where he contracted bronchopneumonia and died.

The immediate causes of death were listed as bronchopneumonia, a left hip fracture and the falls he had suffered, with his dementia, COPD and cardio-renal syndrome listed as underlying factors.

In his report, Mr Steele stated: “I am concerned that a lack of clarity exists in respect of the roles and responsibilities of persons attending upon the home addresses of elderly service users, particularly in the context of what action should be taken when someone is found to have fallen.”

Detailing in his report that the delivery agent had helped move Mr Wilberforce to his chair without a medical examination having been performed, and that she had not been aware the patient had dementia, he said: “Evidence was provided on behalf of the pharmacy that there was no training provided to staff members in respect of how to deal with and what actions should be taken when a service user is found to have had a fall at their home address by a pharmacy delivery agent.

“Evidence was also heard that the majority of service users were elderly persons.”

Mr Steele told the regulator and the pharmacy: “In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action.”

Both parties, who are required to respond to the assistant coroner by September 4 detailing what action they will take or why they believe no action is required, have been approached for comment.