Mr. Christopher Summerhayes · Prevention of Future Deaths report

On 26 September 2018 an inquest was opened was into the death of Mr. Christopher Summerhayes otherwise known as Christopher Harrington. Enquires led by the Coroner’s Office focused on the medical diagnosis and prescription management of this 29 year old man. In parallel, the family had undertaken its independent enquiries and the Inquest has been adjourned to allow those of the family’s concerns which are within the scope of the Inquest, to be addressed as best as possible.

The family were concerned about a previous incident of acute collapse which occurred on 11 August 2018, 5 weeks prior to Christopher’s death. The relevance being that upon emergency admission to the University Hospital of Wales, Christopher was correctly diagnosed as suffering from a pneumonia (adenovirus positive) and was successfully treated. However, the family had mis-understood the cause of this collapse was due to cardiac arrest which, had it been the case, would have required a full cardiac review. The family contends that had such a review been undertaken Christopher’s coronary artery atherosclerosis noted at autopsy would have been identified, treated and his death avoided. This is subject of an investigation by the Concerns Co-ordinator, Cardiff and Vale University Health Board instigated at the request of the family. Open reading the medical reports provided to me, I have concluded the misunderstanding arose from a note taken at the scene of defibrillator use. While one was present no shocks were administered.

The Coroner’s investigation concluded at the end of the inquest on the 20 August 2019. The medical cause of death was 1a. Ischaemic Heart Disease. The conclusion of the inquest was a narrative determination “Atypical early onset coronary artery atherosclerosis on a background of a large number of prescribed complex medications”

Mr. Christopher Summerhayes was found deceased at his home address. He had a significant medical history comprising multiple surgical interventions to treat his double scoliosis and treatment resistant schizophrenia. His medications numbered around 12 daily. Current advice to GPs is that an excess of 5 drugs requires concomitant protector medications and places the patient at an increased risk of hospitalisation. Christopher was prescribed the following ‘complex’ drug regime daily:

Analgesia: Morphine 60mg, Naproxen 1gm, Paracetamol 2-4gms and Pregabalin 600mg (also anti-anxiety)
Gastro protectant (from Naproxen): Omeprazole 20 mg;
Anti-psychotic: Aripiprazole 10mg and Clozapine 600mg - prescribed and monitored by the two Community Mental Health Team (CMHT);
Anti-anxiety: Lorazepam up to 2mg - prescribed and monitored by CMHT
Hyperhidrosis: Oxybutynin 5mg
Laxative: Senna 28mg and Lactulose 18.6-22.2gm
Antibiotic: Doxycycline 200mg
Anti-acne: Zineryt lotion 90mls (topical application)

(1) In relation to Christopher Summerhayes, Clozapine was prescribed as a concomitant medication alongside approximately 11 other drugs including another anti-psychotic medication. Either alone or interaction with other prescribed medication, a large increase in weight occurred to >101kg (BMI 33.1) (reported side effect of clozapine) which had a ‘knock-on’ effect for his cholesterol and lipid levels and cardiovascular system. The usual dose is 200-450mg daily with the maximum dose being 900mg (BNF) which does not consider concomitant medications. Signs of prescription overdose include collapse and hallucinations which could be mistaken for unresolved symptoms of schizophrenia i.e. lack of drug efficacy encouraging dose increase. Blood levels of clozapine may rise in response to smoking cessation which Mr. Summerhayes had advised we was commencing.

(2) He may have suffered from a familial lipid disorder (present in other family members) which had it been confirmed would likely to have contraindicated Clozapine.