Liane Davenport · Prevention of Future Deaths report

On 19/02/2019 I commenced an investigation into the death of Liane Davenport. The investigation concluded at the end of the inquest 4th October 2019. The conclusion of the inquest was Liane Davenport was On high doses of two anti-psychotic medications to control symptoms of chronic schizophrenia, she also had significant coronary artery disease and left ventricular dysfunction. It is most likely that her death at home, Cumbria on December 4th 2019 was due to a combination of her heart disease and the high blood level of Amisulpride needed to control her schizophrenia.
1a Coronary Artery Atherosclerosis
2 Amisulpride toxicity

Liane had a 45 year history of Schizophrenia, and a 10 year history of Lupus with associated arthritic problems. Over the last year of her life she had had hospital admissions for sepsis associated with pneumonia and endocarditis, for which she had prolonged but successful treatment. She had however become physically frail and lost up to 10Kg weight over her final year. She had been on long term antipsychotic treatment requiring high doses of Quetiapine and Amisulpride -800mg daily of each drug – to control her mental state. It was acknowledged at inquest that the Amisulpride dose was significantly higher than the 300mg suggested by BNF but at review shortly before her death her consultant felt it was safe to continue as there had been no physical problems and her blood chemistry and ECG were within normal limits. There was no evidence to suggest she had taken more than her prescribed doses. At post mortem toxicology her plain blood Quetiapine level was 433ng/ml –within the quoted therapeutic range but her Amisulpride level was 10698ng/ml –against a suggested therapeutic upper range of 400ng/ml. ████████ at Leicester comments on the large volume of distribution for Amisulpride which may raise the level somewhat. He tells me he could not find any quoted toxic or lethal ranges but points to a reported case where a level of 9600 was survived with treatment whereas 2 fatal cases involved levels of over 40,000.

[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) Should monitoring of blood levels of powerful antipsychotics be considered and recommended for patients on long term high dose treatment, particularly as they become older & more frail?
(2)--------------------
(3)--------------------