Yemisi Cielto-Opaleye
18 Nov 2024 · Coroner Edwin Buckett · Inner North London
The coroner's concerns
1. lack of patient understanding of death risk from Olanzapine depot
“The risk of death from the use of Olanzapine depot injection needs to be made clear to patients who are going to be given that injection”
2. missed vital signs checks leading to undetected Post Injection Syndrome
“In a psychiatric in-patient setting, there are many demands on staff who can become distracted from their expected duties”
3. approval without verification of SOAD for non-formulary medicine
“There is a risk that approval from a Lead Pharmacist to initiate a non-formulary medicine such as an Olanzapine depot can occur without the Pharmacist knowing whether a SOAD has been obtained”
4. inappropriate use of Olanzapine depot in patients who refuse vital signs checks
“In cases where psychiatric in-patients are known to have a history of refusing vital signs checks, careful consideration and scrutiny should be given as to whether an Olanzapine depot injection is a suitable medication for such patients”