On 14th December 2023, the Coroner, Louisa Fee, found that Joseph Gary Lynch, known as Gary, died on 27th July 2018 at Belfast City Hospital due to brain damage precipitated by a heart attack which was in turn caused by an acute behavioural disturbance following the omission of Clozapine medication. In so finding, the Coroner noted that the death was ultimately due to the omission of the medication.
Mr Lynch had been prescribed medication in association with the treatment of an underlying condition. His admission to Belfast City Hospital, for sleep studies in association with obstructive sleep apnoea, began on 16th July 2018. Due to a series of failings on the part of the Belfast Trust, the Trust failed to ensure that the patient continued to receive his medication which had been prescribed. The error was not noticed for a period of 5 days from 16th July 2018 until 21st July 2018. Mr Lynch suffered a heart attack in the early hours of 22nd July 2018 and was admitted to the Intensive Care Unit. He died subsequently on 27th July 2018.
The Coroner found that there were a number of missed opportunities in the care and treatment of the Deceased between 16th and 22nd July 2018 which she outlined in her narrative findings.
There was a failure to conduct a thorough admission assessment in order to ascertain all medications Mr Lynch was receiving prior to his admission. The patient’s Electronic Care Record (ECR) was used as the only source of information to obtain medicine history and although a minimum of two information sources should have been used, there was a failure to consider other resources, to include information from where the patient resided, the Deceased’s General Practitioner, or his community Pharmacist.
The personnel at his accommodation had in fact furnished information relating to Mr Lynch’s medication at the time of his admission, but this was not identified.
The Coroner found that the sole reliance on the ECR in July 2018 was most unsatisfactory.
When the Plaintiff began to suffer from the effects of the withdrawal of the medication, the Coroner found a further failure to recognise and investigate Mr Lynch’s symptoms of tardive dyskinesia which were evidence from the 18th July 2018. When he ultimately came to care, on 20th July 2018, a plan was devised in order to begin the medication again. There was, however, a further failure to appropriately implement this plan on 20th July 2018 or to recognise that the medication was critical. There was an unacceptable delay in administering the medication, which did not begin until 21st July 2018.
After a further deterioration in Mr Lynch’s condition on 21st July 2018, there was a further failure to devise and implement a management plan addressing the urgency of Mr Lynch’s situation.
Due to the cumulative failures in the management of Mr Lynch’s condition, he began to develop behavioural disturbance as a consequence of his tardive dyskinesia. Security personnel were summonsed to the Ward where he was being treated due to this conduct, and in the course of an attempted restraint, the patient suffered the heart attack from which he did not recover.
In finding that the death was ultimately due to the omission of Clozapine, the Coroner noted the evidence from Dr Cross, Deputy Medical Director of the Trust, who co-authored a report detailing lessons learned following the death of the Deceased and a Level 2 serious adverse incident investigation. The report outlined three topics of lessons learned including processes relating to the medicine reconciliations, communication, and treatment of a distressed patient. The Coroner commended the Belfast Trust for the lessons learned and the changes implemented as a result of Mr Lynch’s tragic death.
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