Maureen Leaver

On 18th November 2013 commenced an investigation into the death of Maureen Leaver, 83 years of age. The investigation concluded at the end of the inquest on the 25th November 2013. medical cause of death given was: 1a. Bronchopneumonia 1b. Hypothermia 1c. Risperidone toxicity and sepsis II. Dementia, Type 2 Diabetes Mellitus, polypharmacy, Stage 3 chronic kidney disease, congestive cardiac failure (likely secondary to hypertensive heart disease) My narrative conclusion was: Mrs Leaver suffered distressing delusions and hallucinations on background of cognitive decline, which required an emergency admission for her own protection on 24th July 2010. During admission she was not fully assessed, investigated or given a formal diagnosis by senior responsible clinician: She was prescribed risperidone_ The dose was increased for uncertain reasons from 2 to 2.5 mg per on 15th September 2010. The prescribing and monitoring of risperidone did not adhere to national or published Iocal guidelines. Signs and symptoms of risperidone toxicity first became apparent on the September 2010 but were not recognised as such: A chest infection was thought to be 'brewing' at the same time. No physical measurements were taken until 26th September 2010. Mrs Leaver was transferred to St Richard's hospital for emergency treatment of profound hypothermia on 26th September 2010. She was placed on the Liverpool Care Pathway on the September and died on 6'h October 2010_ The safeguards in place at the time were inadequate to prevent this unfortunate chain of events from occurring:

Mrs Leaver was admitted into the Harold Kidd Unit under Section

In my opinion action should be taken to prevent future deaths and believe you and your organisation: Sussex Partnership NHS Foundation Trust