Finding into death of H M

Contributing factors

• Presence of non-prescribed olanzapine in post-mortem toxicology
• Unclear route of olanzapine ingestion
• Medication management procedures allowing potential access to other residents' medications
• Possible hyponatraemia secondary to antipsychotic use
• Complex medical history with cerebral palsy, intellectual disability, visual and hearing impairment

Coroner's recommendations

1. Establishment of legal frameworks across disability, health, education, and justice sectors to ensure restrictive practices including chemical restraint are used only as a last resort, in response to significant risks of harm, and under stringent conditions
2. Implementation of independent review, oversight, and proportionality requirements in use of restrictive practices
3. Establishment of Senior Practitioner or equivalent authority to promote reduction and elimination of restrictive practices, oversee compliance, advocate for affected individuals, and provide education and guidance
4. Enhanced medication storage and access controls to prevent unauthorised access to other residents' medications
5. Implementation of visual identification systems (colour, shape description) for blister-packed medications
6. Requirement for witnessed administration of medications to residents
7. Enhanced documentation and reporting systems for any suspected inadvertent medication administration
8. Staff training on recognition of symptoms of hyponatraemia and other medication side-effects in vulnerable populations