Finding into death of Sydney Hugh Kennedy

Contributing factors

• Failure to recognise lithium toxicity despite clinical deterioration
• Inadequate dose review despite documented renal impairment
• Concurrent use of ACE inhibitor (perindopril) which decreases lithium excretion
• Failure to link clinical signs (weight loss, falls, tremor, dysphagia) to elevated lithium levels
• Limited understanding of lithium toxicity presentation at therapeutic serum concentrations
• No account of cumulative risk factors for lithium accumulation (age, renal impairment, weight loss, anorexia)
• Seven-week delay for urgent specialist appointment
• Inadequate monitoring despite deterioration from June 2012

Coroner's recommendations

1. Therapeutic Goods Authority (TGA) should issue an alert to prescribers to exercise caution when prescribing lithium long-term for ageing patients and patients with medical comorbidities
2. Alert should draw prescribers' attention to increased risk of toxicity in long-term lithium use
3. Alert should highlight that clinical presentation changes (including recognised signs and symptoms of lithium toxicity) may indicate toxicity even when target serum lithium concentration is within recommended parameters
4. Victoria should ensure end-of-life decision policies reflect best practice and contemporary guidance