Recurring concern

Unsafe lithium treatment management

First to latest report 12 Jan 2018 — 12 Oct 2023

Reports that mention this concern: 2
Times this concern has been raised: 3
Stated actions linked to this concern: 4

What this concern includes

Includes deficiencies in the end-to-end management of lithium treatment, including prescribing, dispensing, required blood-test monitoring, communication of results or advice, and timely clinical response to lithium-related risks.

What is not included

Excludes failures involving medical attention or medication management that are not specifically related to lithium treatment.
Excludes deficiencies concerning unrelated medicines or general healthcare provision.
Excludes isolated generic communication, staffing or documentation failures unless they are directly tied to the safe management of lithium treatment.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Low Moor Medical Practice1

NHS England1

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

12 Oct2023
West Yorkshire (Western)
Concerns raised1
1. Failure to provide basic medical attention in relation to lithium prescribing and dispensing
Linked response

Low Moor Medical Practice
Stated actions 3
1. Low Moor Medical Practice
  Register Norman Lodge patients as temporary residents so their home practices remain involved in care.
2. Low Moor Medical Practice
  Ensure clinical pharmacists identify medications, including shared-care medicines, that must be issued without interruption.
3. Low Moor Medical Practice
  Discuss with the local pathology laboratory receiving lithium results as individual results rather than within broader biochemistry lists.
Respondent positions 1
1. Low Moor Medical Practice
  Shared-care drugs and intermediate-care units fall outside core general practice and are covered by Local Enhanced Services.
  Outside remit
AI-generated summary

John HOARE · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

John Hoare died at Airedale General Hospital on 31 March 2020 after contracting Covid-19 while detained under the Mental Health Act 1983. The principal concern was a gross failure in lithium prescribing and dispensing after his discharge to a care home, which contributed to deterioration in his mental health and his subsequent detention. The report states that the detention was preventable, although it could not be concluded on the balance of probabilities that it caused his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide basic medical attention in relation to lithium prescribing and dispensing
Wider context from the report
“But the fact remains, secondly, that there had been a gross failure to provide basic medical attention in relation to lithium prescribing and dispensing that resulted in John being sectioned. ”
Source location
John HOARE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Register Norman Lodge patients as temporary residents so their home practices remain involved in care.

Verbatim wording from the response
“Norman lodge - Change to Temporary Registration.”

Source location
Response from Low Moor Medical Practice
Page 2 · response
Published 2 November 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Ensure clinical pharmacists identify medications, including shared-care medicines, that must be issued without interruption.

Verbatim wording from the response
“Medications to always issue.”

Source location
Response from Low Moor Medical Practice
Page 2 · response
Published 2 November 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Discuss with the local pathology laboratory receiving lithium results as individual results rather than within broader biochemistry lists.

Verbatim wording from the response
“Lithium results.”

Source location
Response from Low Moor Medical Practice
Page 2 · response
Published 2 November 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Shared-care drugs and intermediate-care units fall outside core general practice and are covered by Local Enhanced Services.

Verbatim wording from the response
“This issue took place involving a “Shared care Drug” prescribed to a patient in an “Intermediate care Unit”. Both Shared Care Drugs and Intermediate Care units our outside Core General Practice and are covered by Local Enhance Services. The Shared care medication LES covers care in General Practice of patients while they are stable on medication. This patient had been discharged from hospital after admission with Lithium toxicity – by definition – not stable.”

Source location
Response from Low Moor Medical Practice
Page 1 · response
Published 2 November 2023
Open published response
12 Jan2018
Cornwall and Isles of Scilly
Concerns raised2
1. Failure to complete quarterly kidney function and lithium-level monitoring
2. Failure of clinical alert processes to reflect applicable lithium monitoring guidelines
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

NHS England
Stated actions 1
1. NHS England
  Highlight lithium monitoring requirements to GPs and practices and remind them that current BNF and local CCG prescribing guidance is available.
AI-generated summary

Pauline May Pryor · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Pauline May Pryor, a resident of Trevornor Nursing Home receiving lithium treatment, was found unwell on 9 July 2015 and died in hospital on 13 July 2015. The report identified concerns that required quarterly blood tests were not carried out because of unclear communication between the nursing home and GP surgery, and that psychiatric advice to reduce and stop lithium was not seen or followed up.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to complete quarterly kidney function and lithium-level monitoring
Wider context from the report
“• Mrs Pryor suffered from bipolar affective disorder and was on Lithium treatment which had been successful for many years in controlling her mood. Patients on Lithium are required to have quarterly blood tests to check kidney function and lithium levels. This was not carried out for a number of reasons do to with unclear communication between the Nursing Home and GP surgery. The practice did have in place a computer system to highlight test/reviews for certain groups of patients based on “Quality Outcome Framework Targets” (QOF) guidelines and were unaware these did not necessarily mirror the NICE Guidelines or Local Prescribing /Care Guidelines such as in the case of Lithium Toxicity • A blood test on 29th April 2015 showed Mrs Pryor’s kidney function dropped (eGFR 25) despite a lithium test being requested by Nursing Home and GP it did not occurred. As a result of the kidney function test result the GP wrote to Mrs Pryor’s Consultant Psychiatrist for advice on medication. The Psychiatrist replied by e-mail on the 15.6.15 and advised the GP to reduce and stop the Lithium medication. The E-mail was sent to the GP Practice e-mail but was not seen by the GP for reasons unknown nor was the reply chased up ”
Source location
Pauline May Pryor · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of clinical alert processes to reflect applicable lithium monitoring guidelines
Wider context from the report
“• Mrs Pryor suffered from bipolar affective disorder and was on Lithium treatment which had been successful for many years in controlling her mood. Patients on Lithium are required to have quarterly blood tests to check kidney function and lithium levels. This was not carried out for a number of reasons do to with unclear communication between the Nursing Home and GP surgery. The practice did have in place a computer system to highlight test/reviews for certain groups of patients based on “Quality Outcome Framework Targets” (QOF) guidelines and were unaware these did not necessarily mirror the NICE Guidelines or Local Prescribing /Care Guidelines such as in the case of Lithium Toxicity • A blood test on 29th April 2015 showed Mrs Pryor’s kidney function dropped (eGFR 25) despite a lithium test being requested by Nursing Home and GP it did not occurred. As a result of the kidney function test result the GP wrote to Mrs Pryor’s Consultant Psychiatrist for advice on medication. The Psychiatrist replied by e-mail on the 15.6.15 and advised the GP to reduce and stop the Lithium medication. The E-mail was sent to the GP Practice e-mail but was not seen by the GP for reasons unknown nor was the reply chased up ”
Source location
Pauline May Pryor · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Highlight lithium monitoring requirements to GPs and practices and remind them that current BNF and local CCG prescribing guidance is available.

Verbatim wording from the response
“2. Lithium monitoring. Thank you for pointing out that the QOF framework which is designed to reward GPs for quality, is not the mirror of lithium monitoring guidelines. We will ensure that this is highlighted to GPs and practices and a reminder that up to date guidance is available from the latest BNF, and also local CCG prescribing guidelines.”

Source location
2018-0008-Response-by-NHS-England
Page 1 · response
Published 7 March 2018
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Failure to provide basic medical attention in relation to lithium prescribing and dispensing

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to complete quarterly kidney function and lithium-level monitoring

Failure of clinical alert processes to reflect applicable lithium monitoring guidelines

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Stated actions 3

Respondent positions 1

Stated actions 1