Thomas Wedrychowski · Prevention of Future Deaths report

On 31st January 2019 an investigation was commenced into the death of Thomas Wedrychowski and thereafter an inquest was opened on 1st February 2019. On 28th November 2019 I concluded the inquest. I found that the medical cause of death was

1a) diabetic ketoacidosis
1b medication induced diabetes mellitus (Type 1)

My conclusion was that the deceased died by misadventure

The deceased had been diagnosed as suffering from paranoid schizophrenia. For a number of years he was prescribed anti-psychotic medication. Expert evidence at the inquest was to the effect that the medication had caused the deceased to develop diabetes and that such causation was both a direct consequence of taking anti-psychotic medication and also indirect in that the medication contributed to the deceased becoming morbidly obese.

At both primary and secondary health levels it appeared to have been the view that following initial titration and a period of regular checks, annual monitoring for signs of the development of diabetes should be carried out annually as recommended in NICE guideline CG178. However, expert evidence at the inquest suggested that in cases of individuals with a higher risk of developing diabetes, more regular checks were called for. Further there was evidence to the effect that the results of relevant physical healthcare checks had not been shared between primary and secondary healthcare providers. Thus:

(1) I draw to the attention of the National Institute for Health and Care Excellence their guidance CG178 and specifically clause 1.3.6.4 thereof and ask them to consider whether to the directive for an annual test of inter alia HbA1c, there might be added the words:
“or more frequently in those who have a higher baseline risk for the development of diabetes”.

(2) I draw to the attention of Avon and Wiltshire Mental Health Partnership NHS Trust with reference to their planned review of their document entitled “Medicines Guideline: Monitoring psychotropic medication” my first paragraph addressed to the National Institute for Health and Care Excellence and ask them to consider adding similar wording to their recommendations with regard to annual review appearing at page 4 of the present document.
Secondly, I ask the Trust to consider adding advice in the document to the effect that when a patient is prescribed anti-psychotic medication contact be made with the patient’s GP practice (a) informing them of this fact (b) requesting communication thereafter of any physical health findings that might indicate serious side-effects or potential side-effects of the drugs and (c) communicating any relevant physical health findings to the GP practice as well as mental health findings.