Inquest into the death of Andrew Stubbs
Deceased
Andrew Stubbs
Demographics
32y, male
Date of death
2020-08-26
Finding date
2023-08-11
Cause of death
Cerebral oedema secondary to dialysis disequilibrium syndrome
AI-generated summary
Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included: his GP prescribed lithium at an incorrect dose (1250mg instead of 1000mg) for three months and failed to repeat blood tests despite elevated lithium levels and signs of dehydration; hospital teams lacked communication between renal and ICU specialists, failed to conduct risk assessment before escalating dialysis modality, and did not recognise early warning signs (headache) as possible dialysis disequilibrium syndrome rather than lithium toxicity. Clinical lessons include: GPs prescribing lithium require clear guidelines and must verify doses against specialist communications; treating teams managing complex cases across multiple specialties must have explicit communication protocols; rare but serious complications must remain in the differential diagnosis even when other explanations seem dominant.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Prescribed incorrect lithium dose (1250mg instead of 1000mg) for three months
- Failed to repeat blood test after elevated lithium result on 23 June 2020
- Failed to check lithium levels when patient presented with dehydration on 20 August 2020
- Lack of communication between renal team and intensivist team
- Failure to conduct serial risk assessment before commencing intermittent haemodialysis
- Diagnostic anchoring attributing all symptoms to lithium toxicity rather than considering dialysis disequilibrium syndrome
- Failure to contact senior renal physician when headache occurred during dialysis
- Rapid reduction of urea and other solutes via continuous renal replacement therapy followed by more rapid removal via intermittent haemodialysis
- Timing of dialysis session late in afternoon when senior staff unavailable
- Failure to obtain full medical history to clarify chronicity of kidney injury
- Delay in lithium level reporting due to laboratory equipment maintenance
Coroner's recommendations
- South Western Sydney Local Health District should consider providing its Lithium Carbonate Guideline, or a separate guidance document adapted from that guideline, to General Practitioners when a patient prescribed lithium is discharged from the Community Mental Health Service into GP care
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