Mrs A complained about the care and treatment that her late sister, Ms B received from the Health Board. This investigation considered whether given Ms B’s medication history and presenting symptoms, she should have been tested for fluoxetine toxicity1 to inform her diagnosis and/or before being prescribed additional medications and whether fluoxetine toxicity coupled with any other prescribed medication (specifically Oramorph) could have caused, or contributed to, Ms B’s cardiac arrest (when the blood supply to the heart is suddenly blocked).
The investigation found that during Ms B’s admission she did not present with symptoms of moderate to severe fluoxetine toxicity. She did present with some symptoms of mild toxicity, however, these were also symptoms of the differential diagnoses. In light of this, and the fact that Ms B did not report an overdose, it was clinically reasonable that fluoxetine toxicity was not considered as a working diagnosis. Fluoxetine testing is not available in standard clinical practice. This aspect of the complaint was not upheld.
The investigation did not find that fluoxetine coupled with any other medication caused Ms B’s cardiac arrest. However, it did identify concerns regarding the standalone prescription of Oramorph, given the failure to check Ms B’s blood pressure prior to its administration. The uncertainty surrounding this issue represented an injustice. This aspect of the complaint was upheld.
(F/N 1 Ms B was prescribed fluoxetine by her GP. Fluoxetine increases the level of the chemical serotonin in the brain. Serotonin syndrome is a potentially fatal reaction that occurs when the body has too much serotonin. The terms fluoxetine toxicity and serotonin syndrome are used interchangeably in this report.)
The Health Board agreed to: • Provide Mrs A with a written apology.
• Develop an escalation process to ensure that failures to capture observations in deteriorating patients are escalated to appropriate clinicians.
• Remind all staff involved in Ms B’s care on the 22 January to familiarise themselves with the GMC Good Medical Practice.
• Remind all clinical staff that administer prescriptions that a satisfactory blood pressure reading should be obtained before the administering Oramorph and provide evidence of the remedial action it had already agreed to carry out.