Cases/Older Adults

Daughter Reporting Her Mother Took Her Tablets Twice — Free SCA Practice Case

Daughter reporting her mother took her tablets twice

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Marjorie Hughes

Age

80 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. The patient's daughter is calling on her mother's behalf.

Reason for Encounter

"I'm calling about my mum. I think she's taken her tablets twice today by mistake — she gets muddled. I'm worried, and I don't know whether she should skip her next doses."

Medical Records (Marjorie Hughes)

●PMH: Hypertension. Previous stroke. Osteoarthritis.
●Medications (in a monitored dosage system / blister pack): Ramipril 5 mg OD, amlodipine 5 mg OD, clopidogrel 75 mg OD, atorvastatin 40 mg OD.
●Allergies: NKDA.
●Recent notes: Carers visit daily; increasingly forgetful over recent months; lives alone; daughter closely involved.

Patient Script

For the friend playing the patient role

Character Overview: You are Susan, the daughter of Marjorie, who is 80, lives alone with carers visiting, and has become increasingly forgetful over recent months. Today you noticed her blister pack had two days' worth of tablets missing, and she is not due a new one for two days — you think she has taken today's and tomorrow's doses together. When you asked, she said she "didn't want to miss them." She seems physically well in herself. You are worried about the double dose and about her memory, and you want to know whether she should skip her next tablets. You are caring and a little anxious.

Opening Sentence: "Hello Doctor. It's about my mum, Marjorie — she's 80 and getting forgetful. I've noticed her blister pack has two days of tablets missing and she's not due more for two days, so I think she's taken today's and tomorrow's together. She said she didn't want to miss them. She seems okay in herself, but I'm worried — should she skip her tablets tomorrow?"

History if Asked (Data Gathering Phase)

●What happened: "Her weekly blister pack has two days' worth gone, and she's not due a refill for two days. I think she took a double lot today. She said she didn't want to miss them."
●Which medications: "It's her blood-pressure tablets, her blood-thinner, and her cholesterol one — all in the pack together."
●How she is now: "She seems well in herself — no obvious problems. But I'm worried about the extra dose."
●The memory issue: "She's been getting more muddled and forgetful over the last few months. This isn't the first little mix-up."
●What she wants: "I want to know if it's dangerous, and whether she should skip tomorrow's tablets so she doesn't overdose again."

ICE — Ideas, Concerns, Expectations

The daughter does not volunteer this information unprompted. These responses surface only when the candidate explores her perspective.

●Ideas: Susan suspects her mother took the tablets twice by mistake because of her memory. "I think she's just muddled and took them twice."
●Concerns: She is worried the double dose could harm her mother, and — underneath — about her mother's worsening memory and safety living alone. "I'm scared the extra dose could hurt her, and honestly I'm worried about her memory and whether she's safe on her own."
●Expectations: She wants to know if it is dangerous and whether her mother should skip the next doses. "I want to know if it's serious and what to do about tomorrow's tablets."

If Asked — Toxicity, Cognitive, and Systems Screen

The daughter answers these only when directly asked.

●If asked about current symptoms in her mother: "She seems fine — no obvious symptoms."
●If asked about dizziness, light-headedness, or falls (ramipril/amlodipine): "She's not complained of dizziness and hasn't fallen."
●If asked about bruising or bleeding — gums, nosebleeds, blood in urine or stool (clopidogrel): "No bruising or bleeding that I've seen."
●If asked about nausea, tummy pain, or being unwell (GI upset): "No, her stomach seems fine."
●If asked about muscle aches (statin): "No muscle aches mentioned."
●If asked about how the medication is managed: "It's a weekly blister pack from the pharmacy. The carers help a bit, but mostly she takes them herself, and that's clearly going wrong now."
●If asked about how muddled/forgetful she is and daily function: "She forgets things, repeats herself, gets confused with day-to-day stuff. She manages with carers coming in."
●If asked about who else is involved / support: "Carers once a day, I visit most days. No power of attorney set up."
●If asked about previous medication errors: "There have been little mix-ups before, but nothing like this."

Responses to Management (The Negotiation Phase)

●If the Doctor assesses toxicity risk and reassures appropriately: "So a single day's extra dose probably won't seriously harm her, but you want to check she stays well?" (The tested point is a structured toxicity risk assessment rather than blanket alarm or blanket reassurance.)
●If the Doctor advises on the next doses (seeking poisons advice rather than blanket 'skip'): "So I shouldn't just decide to skip her tablets — you'll check the proper advice on that?" (The tested point is safe, specific advice on subsequent dosing, including seeking poisons/TOXBASE guidance, and NOT stopping essential medication without advice.)
●If the Doctor addresses safe administration systems — key: "How do we stop this happening again? Should the carers be giving them?" (The tested point is putting safe administration systems in place given her cognitive impairment.)
●If the Doctor recognises the cognitive issue and arranges assessment: "And her memory — should that be looked into properly?" (The tested point is recognising and arranging assessment of the underlying cognitive decline, without conducting a full memory screen on this call.)
●If the Doctor safety-nets: "What should I watch for, and when do I need to call for help urgently?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Accidental Overdose in Cognitive Impairment

●Older people with cognitive impairment are prone to medication errors, including double-dosing (as here) or missed doses. A reported double dose warrants a structured toxicity risk assessment and action to prevent recurrence.

Structured Toxicity Risk Assessment

●Assess what was taken, how much extra, when, and current symptoms, and consider the specific risks of each drug: hypotension/falls (ACE inhibitors, calcium-channel blockers), bleeding (antiplatelets/anticoagulants), GI upset, and myalgia (statins). A single extra dose of once-daily agents is often low-risk in an asymptomatic patient, but assess individually.

Use Poisons Resources

●Where there is any doubt about toxicity or subsequent dosing, consult TOXBASE / the National Poisons Information Service for specific guidance, rather than guessing. Do not stop essential medication (e.g. antiplatelet for stroke prevention) without proper advice.

Safe Administration Systems — the Key Preventive Step

●Where cognitive impairment makes self-administration unsafe, put safe systems in place: carer-administered/supervised medication, a monitored dosage system with prompts, secure storage, and community-pharmacist involvement — to prevent recurrence.

Recognise the Underlying Cognitive Problem

●A medication error of this kind is often a marker of underlying cognitive decline. Recognise it and arrange appropriate assessment/referral and a review of capacity to manage medication — this is distinct from conducting a full memory screen in the same acute call.

Involve the Team and Plan Ahead

●Involve carers, the community pharmacist, and relevant services; consider a lasting power of attorney and future planning; and support the family carer.

Safety-Netting and Review

●Provide clear safety-netting (symptoms warranting urgent assessment; when to call 999) and arrange follow-up to confirm safe systems and progress the cognitive assessment.

Common Candidate Mistakes in This Case

●Blanket 'skip the tablets' advice: or stopping essential (e.g. antiplatelet) medication unsafely.
●Over- or under-reacting to the double dose: rather than a structured, drug-specific toxicity assessment.
●Not fixing the system: failing to put safe administration systems in place, so the error recurs.
●Ignoring the cognitive issue — or over-doing it: neglecting the underlying decline, or inappropriately attempting a full memory screen on this call.
●Managing entirely via the daughter: not considering a clinical review of the patient where indicated, or omitting safety-netting.

Free MRCGP SCA practice case for GP registrars covering Daughter Reporting Her Mother Took Her Tablets Twice — Older Adults. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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