Ian Allen
17 Aug 2020 · Coroner Louise Hunt · Birmingham and Solihull
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of action on high clozapine blood test results
“In February 2019 a blood test result confirmed that Mr [name redacted] had a high level of clozapine in his blood. This was not acted upon and no further blood test was taken. The clozapine dose was not adjusted as it should have been.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“In February 2019 a blood test result confirmed that Mr [name redacted] had a high level of clozapine in his blood. This was not acted upon and no further blood test was taken. The clozapine dose was not adjusted as it should have been.”
Later report
“There was no system for highlighting high clozapine results in the rio notes which are routinely used by all clinicians.”
Responses
2020-0161-Response-from-Birmingham-and-Solihull-Mental-Health-Trust_Redacted.pdf ↗· Birmingham and Solihull Mental Health NHS Foundation Trust
Stated action · February 2019
“In February 2019 a blood test confirmed that Mr [name redacted] had a high level of clozapine in his blood. This was not acted upon and no further blood test was taken. The clozapine dose was not adjusted as it should have been.”
Stated action
“We have commenced an audit of all patients prescribed Clozapine on Dr 's caseload to ensure that there are no other patients for whom anomalous results have not been considered.”
Stated action
“In addition, we are in the process of issuing a practice alert to all of our Doctors reminding them of the importance of review when anomalous results are evident.”
Stated action
“There is a system in place whereby anomalous results received are escalated to the Consultant, for example, via the Multi-Disciplinary Team meeting, the administrative staff in receipt of paper results or by junior medical staff who have checked electronic investigations; however on this occasion it appears that this failed. We have therefore put in place an additional control whereby our Information Team will send a report to the pharmacy Clozapine Lead of any results >600 so that these can be”
Stated action
“We have existing Multi-Disciplinary team meetings in place across our organisation and are now specifically strengthening the focus on physical health within these meetings utilising a quality improvement approach. This will provide an additional system for checking that periodic tests have taken place, ensuring that they are routinely acted upon when they are abnormal.”
Stated action
“Clozapine has now been added to this project to increase awareness.”
2020-0161-Response-from-Dept-Health-and-Social-Care_Redacted.pdf ↗· Department of Health and Social Care
Stated action · August 2020
“the MHRA communicated advice on monitoring blood concentrations of clozapine and other antipsychotics in the August 2020 edition of Drug Safety Update', which is the MHRA's monthly newsletter for healthcare professionals about medicines safety.”