Nicholas J'Dourou
11 Feb 2025 · Coroner R Brittain · Inner London North
The coroner's concerns
1. inconsistent cross-titration practice without standardized guidance
“cross-titration of medication, when changing from one regimen to another, is commonplace in psychiatric care but that how to undertake this process is determined predominantly by each individual prescriber's own practice, rather than any local or national guidance”
2. lack of electronic monitoring resulting in insufficient observation
“the local psychiatric Trust had undertaken a trial of electronic patient observation (i.e. automated monitoring of respiratory rate, temperature) but that this had been discontinued, owing to patient complaints regarding invasion of privacy”
3. inconsistent cross-titration practice causing potential harm
“I am concerned that this commonplace and important process is seemingly undertaken on the basis of limited consensus and that the variation in care provided could result in future deaths”
Responses
2025-0081-Response-from-Royal-College-of-Psychiatrists-.pdf ↗· Royal College of Psychiatrists
Stated action · later this year
“we have indicated that we intend to increase our visibility in the space of safe medication and prescribing. Work we are currently doing around Clozapine, which started with learnings from a death elsewhere in the country is an example of this. Although the concerns in that case were not directly aimed at the College, we recognised our responsibility to provide evidence-based advice on the safe prescribing and monitoring of Clozapine. The output of this work is due later this year.”