Lynn POYSER · Prevention of Future Deaths report

On 31st March 2014 I commenced an investigation into the death of Lynn POYSER, age 56. The investigation concluded at the end of the inquest on 22nd July 2015. The conclusion of the inquest was ACCIDENT.

Lynn suffered from a number of problems including impaired kidney function, fatty liver disease, Type 2 Diabetes Mellitus, Fibromyalgia and heart failure. She was being prescribed 22 different medicines including Spironolactone when she attended her G.P. for a nurse led chronic illness check on 5th March 2014. Her blood pressure was noted to be 144/80. The registered nurse, not a prescriber, printed out a prescription for 2.5mg Lisinopril only. She took this to the duty doctor in the practice who was not Lynn's regular G.P. After discussion the prescription was signed. It was received in a pharmacy adjacent to the practice on 8th March 2014 and once dispensed was collected by her husband. Arrangements were made for a "blood test", including serum potassium on 24th March 2014. On 22nd March 2014 she was admitted to hospital with a serum potassium of 9.7 mmol / L. Despite appropriate treatment she had a cardiac arrest from which she could not be resuscitated. Her vitreous humour at post mortem had a urea concentration of 41.8 mmol / L and a creatinine concentration of 421 mmol / L.

The cause of death was recorded as:

1a Hyperkalaemic Cardiac Arrhythmia
1b Acute on Chronic Renal Failure
1c Co-prescription Spironolactone and Lisinopril

1: Evidence was presented at the inquest to the effect that the interaction between Lisinopril and Spironolactone is well known, and that Lisinopril can precipitate deterioration in a patient's renal function. NICE published guidelines on initiation of Angiotensin converting enzyme inhibitor therapy indicates that patients should be reviewed one to two weeks after initiation of therapy and have their renal function and electrolyte status checked 10 – 14 days after initiation of ACEI therapy. This is re-iterated in LCHS guidance. The expert evidence at the inquest pointed out that, following a report of a trial in 1999 "The Randomised Aldactone Evaluation Study", there was an increase in the co-prescription of Spironolactone and Lisinopril in heart failure, immediately followed by an increase in hospital admissions and subsequent deaths associated with hyperkalaemia.

Those to whom I make this report may wish to consider whether or not the current guidance relating to the co-prescription of ACEI drugs, such as Lisinopril, and Spironolactone draws sufficient attention to the need for care and caution and the need to take a holistic view of the best interests of the patient.