Lewis James Doyle · Prevention of Future Deaths report

On 17/01/2019 I commenced an investigation into the death of Lewis James Doyle aged 80. The investigation concluded at the end of the inquest on 24 June 2019. The conclusion of the inquest was: An accidental death

The Medical Cause of death was

I a Organising Pneumonia

I b Traumatic injuries to feet (with distal amputations), severe coronary artery disease and metastatic carcinoma of the prostate

I c

II

Mr Lewis James Doyle had a past medical history of Coronary Artery Disease, Parkinson’s disease, Cerebral meningioma, Adenocarcinoma of the prostate & a longstanding recurrent depressive illness (without psychosis) for which he was prescribed fluoxetine, mirtazapine and lithium. On 10th September 2018, Mr Doyle was admitted to Arrowe Park hospital following an episode of Acute Coronary Syndrome. On the 14th September 2018, a decision was made to suspend lithium medication, as the level was 1.4, which was biochemically toxic. On the 20th September 2018, the Lithium was stopped and later the same day Mr Doyle suffered a cardiac arrest. On 24th September 2018, Mr Doyle was transferred to Liverpool Heart & Chest Hospital where he underwent a procedure to insert coronary artery stents and an internal cardiac defibrillator before being discharged home. On 22nd October 2018, Mr Doyle was seen by his General Practitioner for a review of medication relating to his enlarged prostate. At 12.53 on the 22nd October 2018, Mr Doyle fell in front of a train at Bebington Railway Station. Mr Doyle was disorientated in thought and there is no evidence that he intended to self-harm. It is possible that he was experiencing a psychosis. Mr Doyle suffered head and lower limb injuries was taken to University Hospital Aintree where he underwent a bilateral foot amputation. On 30th October 2018 after a discussion between a Merseyside psychiatrist and a University Hospital Aintree cardiologist, the decision was made to re-introduce lithium to Mr Doyle. It is found that Lithium had to be stopped when it was at a toxic level and there were no alternatives for mood stabilisation, which did not carry a risk to his cardiac health. The Lithium was reintroduced when Mr Doyle was medically stable minimising the risk of a further cardiac event. On 17th November, once stable Mr Doyle was transferred to Arrowe Park Hospital to continue his treatment on the orthopaedic ward. During his time at Arrowe Park, Mr Doyle developed a chest infection for which he was treated with antibiotics, which were escalated when his symptoms worsened, he became breathless and his oxygen requirements increased. Chest X-Rays demonstrated pulmonary oedema & furosemide was then added to clear his lungs. On 8th January 2019, it appeared there was no clinical improvement and furthermore Mr Doyle was deteriorating. The decision was made to turn off the internal cardiac defibrillator to prevent painful & inappropriate shocks. Mr Doyle passed away and his death was confirmed at 20:58 on 8th January 2019.

When Mr Doyle was discharged from the Liverpool Heart and Chest Hospital the GP discharge letter was sent to his GP. Mr GP Doyle was receiving treatment for Acute Coronary Syndrome but also mental health care for a Recurrent Depressive Illness (without Psychosis). Lithium had to be stopped not only because it was at a toxic level but also because of the effect of this and alternate medications on cardiac health. It occurred during the inquest that in similar scenarios better patient care could be delivered, if discharge letters were sent to all current medical attendants, whether in primary, secondary or tertiary care. Information with regarded to suspended or stopped medication was needed by the original prescribers.