Challenge to Trust over drug levels

HEALTH bosses have been given 90 days to tell a coroner if action can be taken to avoid fatal consequences of long-term prescribed drug use.

Oldham and district coroner Simon Nelson made the call to Pennine Care Trust after 56-year-old Rosalind Ken-nedy, from Royton, died from a build-up of anti-psychotic drugs in her system.

The coroner accepted they had been appropriately prescribed and properly administered by social care workers who visited her four times a day.

But undetected hepatitis, which affected the ability of her liver to deal with toxins, resulted in a build-up which contributed to her death.

The situation was made worse by Rosalind not eating and drinking properly in the days before she died, causing dehydration.

Friday’s inquest heard that Rosalind, who had learning difficulties and was on a cocktail of drugs to combat schizophrenia, died at her home in Lancaster Square.

One of her team of support workers, Diane Chappell, was with her when she collapsed.

She called emergency services and administered mouth-to-mouth resuscitation and chest compressions until they arrived, but paramedics were unable to save her.

Rosalind had had a visit from a doctor earlier the same day, November 13 last year, who put her reluctance to eat and drink down to psychological behaviour.

Mr Nelson feared Rosalind may have overdosed on her medication, which was kept away from her in a locked cupboard, and insisted the number of tablets remaining after her death were counted and checked off against the number she was prescribed.

He took the action after reading a toxicology report which suggested she may have had up to 15 times the level of procyclidine in her blood than would have been expected.

But Dr Gwendolen Ayers, consultant clinical scientist with an interest in toxicology, warned there was a wide margin of error, and said Rosalind had none of the symptoms associated with an overdose of the drug before she collapsed.

She said the “normal” prescribed dose may have been too high for her because hepatitis meant her liver was not working properly and made her vulnerable to retaining the drug in her body.

A post mortem report revealed the cause of death as the side effects of appropriately prescribed and administered medication of a therapeutic dose.