Pauline Pryor
12 Jan 2018 · Coroner Emma Carlyon · Cornwall and the Isles of Scilly
The coroner's concerns
1. failure to conduct quarterly lithium blood tests
“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.”
2. missed critical lithium toxicity alert
“ABlood test on 29" April 2015 showed Mrs [name redacted] kidney function dropped (EGFR 285) 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 [name redacted] 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”
3. failure to perform required lithium monitoring
“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”
4. inadequate system configuration for lithium monitoring
“The practice did have in place a computer system to highlight test/reviews for certain groups of patients based on”