Inquest into the Death of Kim Martin FRANKER

Contributing factors

• High-dose benzhexol prescription (20mg/day) re-prescribed by GP shortly after hospital discharge despite plan to cease
• Inadequate communication between GP and community mental health team
• Failure of GP to respond to psychiatrist's letter about medication abuse concerns
• Discharge summary possibly not received by GP or not acted upon
• Patient abuse of prescription medications despite restricted dispensing regime
• Undiagnosed cardiomyopathy increasing susceptibility to drug toxicity
• Concurrent use of amphetamine-type stimulants with benzhexol and antipsychotics
• Morbid obesity and related medical complications
• Patient's lack of insight into mental illness and ongoing substance abuse
• Absence of real-time prescribing data system preventing awareness of overlapping medications from multiple providers

Coroner's recommendations

1. Improve coordination and communication between general practitioners and community mental health services, particularly regarding patients with complex medication regimens and substance abuse histories
2. Implement systematic mechanisms for GPs to engage with specialist mental health teams when discharge plans involve medication changes or cessation
3. Develop and implement real-time prescribing electronic data systems to provide awareness of all medications prescribed by multiple healthcare providers
4. Establish protocols for GPs to contact supervising psychiatrists before re-prescribing medications recently ceased or reduced by hospital teams
5. Include guardianship orders and their outcomes in discharge communications to primary care providers
6. Ensure discharge summaries explicitly document medication management plans and intended cessation of medications