Ms Lisa Grant · Prevention of Future Deaths report

On the 12 August 2019, I commenced an investigation into the death of Ms Lisa Grant. The investigation concluded at the end of the inquest on the 15 December 2020. The conclusion of the inquest was a short form conclusion of natural causes.

The cause of death was:

1a Bilateral Pulmonary Embolism
1b Deep Vein Thrombosis

i) Ms Grant was admitted to Hallam Street Hospital on the 29 July 2019 under s3 MHA. She had been diagnosed with Bipolar Affective Disorder and had numerous previous admissions.

ii) In terms of her medical history she had insulin dependent diabetes, iron deficiency anaemia, sickle cell trait and Raynaud's disease. Her medication included risperidone which is an antipsychotic or neuroleptic.

iii) Ms Grant had gained weight and was obese. One of the common side effects of risperidone medication included eating more and therefore weight gain. Another rare risk factor is the risk of developing venous thromboembolism (VTE).

iv) On the 1 August 2019 she collapsed on the ward and became unresponsive. Despite resuscitation attempts by staff and paramedics she sadly died a short time later at Sandwell Hospital.

1. Evidence emerged during the inquest that both the consulting Psychiatrist and the Hospital’s Manager said that Ms Grant was assessed upon admission to hospital in accordance with the national guidelines for the assessment for Deep vein thrombosis (DVT). As per the guidance criteria checklist, the clinician considered that there was no significant reduction in mobility, and therefore no further treatment or assessment for this condition was required.

2. Miss Grant had a significantly increased risk of DVT due to the effects of obesity and inactivity. In addition, there was a rare but recognised side effect of Risperidone.