Megan Nicole JONES · Prevention of Future Deaths report

On 1st August 2018, I commenced an investigation into the death of Megan Nicole JONES, aged 28. The investigation concluded at the end of the inquest on 3rd April 2019. The conclusion of the inquest was “Megan Nicole JONES died pursuant to a recognised complication of a necessary medication regime.”

The medical cause of death was found to be:
1a Cardiac Arrhythmia
1b Intake of a higher than Optimal Combination Dose of Antipsychotic Medications
1c
II

1) Megan Nicole JONES was born on 19th March 1990. At the time of her death she was 28 years old and was unemployed.

2) Miss JONES was found dead by her daughter at around 0800 hours at her home address of ████████, Shanklin, Isle of Wight. She had a long history of mental health issues, including schizo-affective disorder, obsessive compulsive disorder and suicidal thoughts which included hearing voices telling her to kill herself.

3) She was prescribed Amisulpride (an antipsychotic drug), Clozapine (another antipsychotic drug) and Trazodone (an antidepressant and sedating drug).

4) The toxicology which was undertaken as part of the post-mortem examination revealed that the Clozapine was found at a level indicating high dose/chronic therapeutic use. This drug is used to reduce the risk of recurrent suicidal behaviour. At high dose, it can lead to a prolongation of the cardiac QT interval and lead to cardiac arrhythmia and hypotension. According to the toxicology report, there is an apparent overlap between the concentrations obtained in non-fatal overdoses and those observed in fatalities.

5) The evidence given by Megan’s Consultant Psychiatrist was that the dose that Miss JONES was being prescribed of her two antipsychotic medications was 108% of the British National Formulary (“BNF”) limit (with Clozapine at 58% and Amisulpride at 50% of the maximum recommended dose). The Consultant Psychiatrist indicated that where a patient is prescribed a combination antipsychotic regime and/or is being prescribed more than 100% of the BNF antipsychotic prescription, this situation requires greater vigilance by the treating clinicians due to the potential risk of cardiac arrhythmias – especially where a patient was abusing laxatives, which Miss JONES was known to be doing.

6) It is believed that Miss JONES suffered a fatal cardiac arrhythmia due to the higher than optimal recommended dose of her combined antipsychotic medications.

1. It is clear that there is no formal policy or protocol in place for GP’s surgeries with regard to the monitoring of those patients who are prescribed Clozapine antipsychotic medication.

2. It would be relatively simple for the CCG to instigate such a policy or protocol that where a patient is prescribed Clozapine, they must be monitored on a regular basis to ensure that there is some form of QTc recording.

3. This policy/protocol is especially important where the patient is prescribed more than 100% of the BNF limit of antipsychotic medication(s).