Finding into death of Margareta Snopek

67y · Female·Lithium toxicity with chest infection and bipolar disorder; Alzheimer's disease as contributing condition

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.