Finding into death of Margareta Snopek
Deceased
MARGARETA SNOPEK
Demographics
67y, female
Date of death
2008-03-18
Finding date
2014-02-05
Cause of death
Lithium toxicity with chest infection and bipolar disorder; Alzheimer's disease as contributing condition
AI-generated summary
Mrs Snopek, aged 67 with bipolar disorder on long-term lithium, was prescribed coversyl (an ACE inhibitor) by Dr A. in January 2008 for hypertension. This combination is contraindicated as ACE inhibitors impair renal function and reduce lithium excretion, risking toxicity. Key failures included: (1) lithium levels tested only 3 times over many years despite guideline recommendations for annual monitoring; (2) Dr A. failed to check lithium levels before or after commencing coversyl, and didn't enter lithium into the electronic medical record (it remained in handwritten notes); (3) the prescribing system failed to flag the contraindication; (4) the dispensing pharmacy apparently did not contact the prescriber about the concerning drug combination. Mrs Snopek developed elevated lithium levels (1.8 mmol/L), renal impairment and elevated sodium. She was admitted in March 2008, treated with haemofiltration, but died of lithium toxicity complicated by chest infection. Preventable deaths from lithium-ACE inhibitor interactions require awareness, checking renal function and lithium levels before commencing ACE inhibitors, and integrated electronic records.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Failure to monitor lithium levels adequately over many years (only 3 tests, last in 2003)
- Prescription of coversyl (ACE inhibitor) without checking lithium levels or renal function beforehand
- Failure to recognise contraindication between lithium and ACE inhibitors
- Incomplete transfer of patient medication information from handwritten notes to electronic medical record
- Coversyl prescribed without documented discussion of drug interactions or monitoring requirements
- Failure to check lithium levels within 2-4 weeks of starting coversyl
- Electronic prescribing system did not alert to contraindication due to incomplete medication list
- Pharmacy apparently did not contact prescriber regarding contraindicated combination
- Neurologist not alerted to the lithium-coversyl interaction despite reviewing medications
Coroner's recommendations
- Doveton Medical Centre to undertake regular audits to ensure each patient has a legible individual health record complying with Royal Australian College of General Practitioners Standards for General Practice
- Doveton Medical Centre to record all allergies and medications electronically
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