Source · Prevention of Future Deaths
Lynn Poyser
Ref: 2015-0295
Date: 23 Jul 2015
Coroner: ARW Forrest
Area: South Lincolnshire
Responses identified: 0 / 3
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Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for more caution and a holistic patient view.
Date
23 Jul 2015
56-day deadline
17 Sep 2015 est.
Responses identified
0 of 3
Coroner's concerns
Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for more caution and a holistic patient view.
View full coroner's concerns
Evidence was presented at the inquest to the effect that the interaction between Lisinopril and Spironolactone is well known, and that Lisinopril can precipitate deterioration in a patient's renal function. NICE published guidelines on initiation of Angiotensin converting enzyme inhibitor therapy indicates that patients should be reviewed one to two weeks after initiation of therapy and have their renal function and electrolyte status checked 10 14 days after initiation of ACEI therapy. This is re-iterated in LCHS guidance: The expert evidence at the inquest pointed out that; following a report of a trial in 1999 "The Randomised Aldactone Evaluation Study" , there was an increase in the co-prescription of Spironolactone and Lisinopril in heart failure, immediately followed by an increase in hospital admissions and subsequent deaths associated with hyperkalaemia_ Unit 1 , Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire gov.uk Her
A R W Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Her Majesty's Senior Coroner for South _Lincolnshire Those to whom make this report may wish to consider whether or not the current guidance relating to the co-prescription of ACEI drugs, such as Lisinopril, and Spironolactone draws sufficient attention to the need for caution and the need to take a holistic view of the best interests of the patient:
A R W Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Her Majesty's Senior Coroner for South _Lincolnshire Those to whom make this report may wish to consider whether or not the current guidance relating to the co-prescription of ACEI drugs, such as Lisinopril, and Spironolactone draws sufficient attention to the need for caution and the need to take a holistic view of the best interests of the patient:
Report sections
Investigation and inquest
On 31st March 2014 commenced an investigation into the death of Lynn POYSER, age The investigation concluded at the end of the inquest on 22nd 2015. The conclusion of the inquest was ACCIDENT .
Circumstances of the death
Lynn suffered from a number of problems including impaired kidney function, fatty liver disease, Type 2 Diabetes Mellitus, Fibromyalgia and heart failure: She was being prescribed 22 different medicines including Spironolactone when she attended her G.P.for a nurse led chronic illness check on 5th March 2014. Her blood pressure was noted to be 144/80 The registered nurse, not a prescriber, printed out a prescription for 2.5mg Lisinopril once daily for Lynn: She took this to the duty doctor in the practice who was not Lynn's regular G.P. After Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire gov.uk July
A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Majesty's Senior Coroner for South Lincolnshire discussion the prescription was signed. It was received in a pharmacy adjacent to the practice on 8th March 2014 and once dispensed was collected by her husband:. Arrangements were made for a "blood test", including serum potassium on 24th March 2014. On 22nd March 2014 she was admitted to hospital with a serum potassium of 9.7 mmol
A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Majesty's Senior Coroner for South Lincolnshire discussion the prescription was signed. It was received in a pharmacy adjacent to the practice on 8th March 2014 and once dispensed was collected by her husband:. Arrangements were made for a "blood test", including serum potassium on 24th March 2014. On 22nd March 2014 she was admitted to hospital with a serum potassium of 9.7 mmol
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have the power to take such action:
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Report details
- Reference
- 2015-0295
- Date of report
- 23 July 2015
- Coroner
- ARW Forrest
- Coroner area
- South Lincolnshire
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Sep 2015 (estimated).
Sent to
- Lincolnshire Community Health Services
- Medicines and Healthcare products Regulatory Agency
- National Institute for Health and Care Excellence