Source · Prevention of Future Deaths

Pauline Pryor

Ref: 2018-0009 Date: 12 Jan 2018 Coroner: Emma Carlyon Area: Cornwall and the Isles of Scilly Responses identified: 1 / 1 View PDF

Critical communication failures between the nursing home and GP, an inadequate system for monitoring lithium toxicity, and an unread consultant email led to missed essential blood tests and unmanaged medication changes.

Date 12 Jan 2018

56-day deadline 2 May 2018 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

_ May Pryor July Pryor July not being being

Mrs Pryor suffered from bipolar affective disorder and was on Lithium treatment which had been successful for many years in controlling her mood Patients on Lithium are required to have quarterly blood tests to check kidney function and lithium levels. This was not carried out for a number of reasons to do with unclear communication between the Nursing Home and GP surgery. The practice did have in place a computer system to highlight testlreviews for certain groups of patients based on "Quality Outcome Framework Targets" (QOF) guidelines and were unaware these did not necessarily mirror the NICE Guidelines or Local Prescribing ICare Guidelines such as in the case of Lithium Toxicity A Blood test on 29"h April 2015 showed Mrs Pryor's kidney function dropped (EGFR 25) and despite a lithium test being requested by Nursing Home and GP it did not occurred. As a result of the kidney function test result the GP wrote to Mrs Pryor's Consultant Psychiatrist for advice on medication: The Psychiatrist replied by e-mail on the 15.6.15 and advised the GP to reduce and stop the Lithium medication. The E-mail was sent to the GP Practice e-mail but was not seen by the GP for reasons unknown nor was the reply chased up

Responses

1 respondent

NHS England NHS / Health Body

PDF

Action Planned

NHS England will raise the need for formal communication between agencies regarding patients with mental health issues in their GP bulletin and provide information to the LMC for distribution. They will also highlight the importance of up-to-date lithium monitoring guidelines to GPs and practices. (AI summary)

View full response

Dear Dr Carlyon,

Reference Regulation 28 Report following the inquest of Pauline Pryor

1. Patients with serious mental health issues are usually cared for by a number of agencies and they may lack capacity or it may be intermittent, it is vital communication is effective.

Statutory agencies such as the mental health services and GP surgeries have long standing means of communications when formally referred and treated. However, this case has raised the need to ensure the occasional interval communication is treated as formally. In addition when patients are cared for in a residential or nursing home setting then it is equally important that any verbal message is followed up by written instructions if possible.

NHSE will raise this concern in our GP bulletin and also provide information to the LMC for distribution.

2. Lithium monitoring. Thank you for pointing out that the QOF framework which is designed to reward GPs for quality, is not the mirror of lithium monitoring guidelines. We will ensure that this is highlighted to GPs and practices and a reminder that up to date guidance is available from the latest BNF, and also local CCG prescribing guidelines. I have attached for your information the proposed communications.

With best wishes,

Report sections

Investigation and inquest

An Investigation into the death of Pauline was opened on 17th 2015 and an inquest opened on 20th January 2016. An Inquest hearing was held on 14th November 2017 at Truro Municipal Buildings, Truro where the cause of death was found to be 1a Bronchopneumonia 1b Chronic Obstructive Pulmonary Disease II Renal failure, Lithium Toxicity and the death was considered to be the result of natural causes.

Circumstances of the death

Pauline suffered from bi-polar affective disorder and was being treated with Lithium: She was a resident of Trevaylor Nursing Home, Newmill Road, Gulval. On July 2015 she was found in her room with reduced conscious with the occasional arm jerking She was admitted to the Royal Cornwall Hospital; Treliske, Truro and diagnosed with acute kidney injury, severe metabolic acidosis, septic shock of uncertain cause and lithium toxicity. She received renal replacement therapy which improved her kidney function and lithium toxicity. She deteriorated and died on 13th 2015 from bronchopneumonia as result of her severe chronic obstructive pulmonary disease. She was on Lithium which required her to have quarterly blood tests which due to communication issues between the GP surgery and Nursing Home did not occur A reply to a letter from the mental health service to the GP was not actioned due the GP not receiving due to the e-mail received by the GP for unknown reasons or chased up.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation have the power to take such action: To highlight the importancelrequirement of good clear communication between health agencies when medical and nursing care is shared between the Mental Health Trust; GP and Nursing Homes especially where the patient is suffering from Mental Health issues To ensure that all GP's are aware the QOF targets do not necessarily mirror NICE Guidelines or Local Prescribing ICare Guidelines e.g: Lithium Treatment; and the requirement for GP's to have their own systems in place to monitor the timeliness of testslreviews

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Shared signals

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Report details

Reference: 2018-0009
Date of report: 12 January 2018
Coroner: Emma Carlyon
Coroner area: Cornwall and the Isles of Scilly

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 May 2018 (estimated).

Sent to

NHS England

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.