Pauline May Pryor · Prevention of Future Deaths report

An Investigation into the death of Pauline May Pryor was opened on 17th July 2015 and an inquest opened on 20th January 2016. An Inquest hearing was held on 14th November 2017 at Truro Municipal Buildings, Truro where the cause of death was found to be 1a Bronchopneumonia 1b Chronic Obstructive Pulmonary Disease II Renal failure, Lithium Toxicity and the death was considered to be the result of natural causes.

Pauline May Pryor suffered from bi-polar affective disorder and was being treated with Lithium. She was a resident of Trevornor Nursing Home, Newmill Road, Gulval. On 9th July 2015 she was found in her room with reduced conscious with the occasional arm jerking. She was admitted to the Royal Cornwall Hospital, Treliske, Truro and diagnosed with acute kidney injury, severe metabolic acidosis, septic shock of uncertain cause and lithium toxicity. She received renal replacement therapy which improved her kidney function and lithium toxicity. She deteriorated and died on 13th July 2015 from bronchopneumonia as result of her severe chronic obstructive pulmonary disease.

She was on Lithium which required her to have quarterly blood tests which due to communication issues between the GP surgery and Nursing Home did not occur. A reply to a letter from the mental health service to the GP was not actioned due the GP not receiving due to the e-mail not being received by the GP for unknown reasons or being chased up.

• Mrs Pryor suffered from bipolar affective disorder and was on Lithium treatment which had been successful for many years in controlling her mood. Patients on Lithium are required to have quarterly blood tests to check kidney function and lithium levels. This was not carried out for a number of reasons do to with unclear communication between the Nursing Home and GP surgery. The practice did have in place a computer system to highlight test/reviews for certain groups of patients based on “Quality Outcome Framework Targets” (QOF) guidelines and were unaware these did not necessarily mirror the NICE Guidelines or Local Prescribing /Care Guidelines such as in the case of Lithium Toxicity

• A blood test on 29th April 2015 showed Mrs Pryor’s kidney function dropped (eGFR 25) despite a lithium test being requested by Nursing Home and GP it did not occurred. As a result of the kidney function test result the GP wrote to Mrs Pryor’s Consultant Psychiatrist for advice on medication. The Psychiatrist replied by e-mail on the 15.6.15 and advised the GP to reduce and stop the Lithium medication. The E-mail was sent to the GP Practice e-mail but was not seen by the GP for reasons unknown nor was the reply chased up