According to the corner’s report, external, Coastal Homecare had digitally recorded the NHS records of Fisher’s care.
“Coastal Healthcare indicated that a mistake was made when documenting the medications”, leading to one epilepsy drug being missed for six days.
Taylor said: “This mistake was not spotted at all and there is no system in place to cross check what has previously been given when there is a handover between different care agencies.
“Nor was there any liaison with the community pharmacy who regularly dispensed Mr Fisher’s medication.”
Fisher was first diagnosed with epilepsy in 2020 and was admitted to hospital twice the following year, according to Taylor.
“He remained seizure free for almost four years” until being admitted to hospital shortly before his death.
Coastal Homecare said its thoughts were with Fisher’s family and it would “continue to work with all involved… to ensure that we are all able to learn from this”.
The NHS trust said it wanted to “express our sincere condolences to the family of Mr Fisher” and would “provide a full response to the coroner in due course”.
The agency and the NHS trust have until 13 May to respond to the coroner.