Martin Glyn Baker · Prevention of Future Deaths report

On 9 September 2016, I commenced an investigation into the death of Martin Glyn Baker, then aged 48. The investigation concluded at the end of the inquest on 19 April 2018. The conclusion of the inquest was prescription drug-related death. It is likely Mr Baker suffered from a slow metabolism which caused potentially toxic levels of venlafaxine, prescribed to him, to build up. Together with a deteriorating physical condition and mild myocardial scarring found at post-mortem, it is likely this induced a fatal cardiac arrhythmia.

The medical cause of death was given as
1a) drug toxicity

Mr Baker suffered with mental health issues for over 20 years. He had previously attempted suicide on a number of occasions. After a failed attempt to take his own life following a jump from height he fractured his spine and was left confined to a wheelchair. Psychiatric support for Mr Baker was provided through Livewell South-west and I heard at inquest from ████████ and ████████ both of whom saw the deceased. Prior to the deterioration in Mr Baker’s condition that led to his demise, ████████ had decided to stop a prescription of lithium. This was as a consequence of excessive thirst complained about by Mr Baker which, in turn, led to the consumption of a large number of fizzy drinks and resulted in problems with urinary incontinence. ████████ was unaware, at the time of his decision, that there had been earlier failed attempts to stop the lithium prescribed to Mr Baker. ████████ was also unaware that Mr Baker had signed a form of consent authorising Livewell South-west to discuss care arrangements made for him with his family.

[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) It was accepted in evidence that there had been a lack of communication with the family. They had not been involved in any psychiatric reviews instead, on one occassion, a consultant was left to rely upon information provided by a junior healthcare assistant. At inquest I expressed my view that where a patient has signed a consent form authorising discussion of relevant events with the family, the default position should be that there will be involvement of the family in the absence of any good reason not to do so, for example, a patient’s subsequent express instruction not to share something with the family. In this case the family were unaware that Mr Baker had been discharged from psychiatric support and were unaware of what to do in the event of deterioration in Mr Baker’s condition.
(2) It was also accepted in evidence that at the time of these events there was a shortage of care coordinators something described as “very far from ideal.” I was advised that this situation has now been corrected. Nevertheless, it was the clear view of the family, which I accepted, that in the absence both of a care coordinator and the involvement of the family there had been no one to act as an advocate on Mr Baker’s behalf, something that had been to his detriment.
(3) It was accepted in evidence by ████████ that his risk assessment failed to address periodic impulsivity that Mr Baker demonstrated. I found this was not causative of the death. Nevertheless, I felt there was a point of learning that may well have a bearing in the care of future patients and I felt it appropriate to bring it to your attention.