Resmije Ahmetaj

1. 1. lack of mental state examination during clozapine clinic visits

   “EPUT mental health team were relying on the clozapine clinic staff to monitor Ms [name redacted] mental health, but this was not the purpose of the clinic. Staff took blood samples and vital signs with a quick chat that took about 5 minutes and were not undertaking a mental state examination.”

2. 2. confusion over antidepressant dosage and delayed GP communication

   “There was confusion about the mental health Trust prescribing dose for Ms [name redacted] antidepressant medication and an overreliance on discussions with her rather than checking the prescription dose and communication with the GP was delayed.”

3. 3. subtherapeutic clozapine levels not acted upon despite patient concerns

   “month blood anti-psychotic to check clozapine levels assay was taken on 3 June and the results reported on 7 June were sent to the psychiatrist and showed markedly subtherapeutic blood levels of antipsychotic medication. This subtherapeutic level was not acted upon and was contrary to: a. Ms [name redacted] insisting she was compliant with her medication b. Ms [name redacted] did not have any noted risks that would cause interference with her medication. c. Ms [name redacted] informed EPUT clinicians that: i. On 24 June she thought her medication Clozapine was not working ii. On 27 June she no longer wished to take her prescribed antipsychotic medication , and iii. Did not agree she had Schizophrenia, and iv. wanted to revert to a previous medication Quetiapine”

4. 4. incomplete record-keeping of patient symptoms and medication compliance

   “The mental health Trust record-keeping did not contain all relevant information relating to the care and treatment there were omissions relating to symptoms and potential signs of deterioration and compliance with medication.”

5. 5. delayed management of clozapine-related constipation

   “Clozapine constipation was raised as a serious side effect such that there is a Trust policy to manage this matter. This was not dealt with within the Trust for Ms [name redacted], and it took two weeks to raise this for the GP to manage.”

6. 6. lack of fall prevention on penultimate floor walkway

   “The car park has a link walkway to residential housing on the penultimate floor from where [the deceased] fell. The top floor has mitigation that would prevent a person from jumping/falling but the penultimate floor that has a pedestrian link walkway does not. There is likely to be more pedestrian footfall on the penultimate floor as a consequence and any fall from this height would inevitably be fatal.”

Linked reports