Michael Brian Sullivan · Prevention of Future Deaths report

On 22nd December 2022 I commenced an investigation into the death of Michael Brian Sullivan. The investigation concluded on the 16th May 2023 and the conclusion was one of Narrative: Died of natural causes exacerbated by lithium toxicity. The medical cause of death was 1a) Bronchopneumonia; II) Bipolar disorder, Lithium toxicity, chronic obstructive pulmonary disease

Michael Brian Sullivan had schizophrenia and was bipolar. He took lithium medication. He deteriorated at home and was admitted to Stepping Hill Hospital after concerns were raised by his family. He was found to have pneumonia and lithium toxicity, a complication of his bronchopneumonia and related to his dehydration. He deteriorated despite treatment and died at Stepping Hill Hospital on 17th December 2022.

The evidence before the inquest was that Mr Sullivan was a vulnerable person with a complex mental health history. The inquest heard evidence that GPs could access a Crisis Review Team to assess patients such as Mr Sullivan. However, the evidence before the inquest was that there seemed to be delays between referrals and assessments. It was unclear if these were due to a lack of understanding by GPs on how the CRT could be used or how patients were prioritised within the CRT or a lack of effective triage by GPs before referral or the CRT following referral. In his case the concern was raised by his family on 13th December 2022 with the GP. The GP referred him to the CRT that day indicating he needed an assessment on 14th December 2023 for confusion following a fall and a possible UTI. At the assessment on 14th December 2023 at 11am Mr Sullivan was seriously unwell.