Mrs R-W - Non-inquest findings

83y · Female·Hyponatraemic encephalopathy due to adverse effects of citaprolam and duloxetine administration

An 83-year-old woman with pre-existing SIADH-related chronic hyponatraemia died from hyponatraemic encephalopathy following antidepressant therapy. Critical clinical lessons include: (1) the importance of accessing prior medical records—the prescribing physician was unaware of the patient's previous hyponatraemia diagnosis due to hospital record management failures; (2) recognising that both citalopram and duloxetine carry hyponatraemia risk, particularly in elderly patients with fluid balance disturbance; (3) the need for frequent biochemical monitoring when prescribing such medications in at-risk patients; (4) appropriate escalation and communication during clinical deterioration—nursing staff failed to escalate critical observations to senior staff using early warning systems; (5) inter-hospital transfer processes require clear communication and unified management plans rather than fragmented consultant involvement. Earlier identification of the chronic hyponatraemia, more frequent sodium retesting, and stricter documentation of escalation procedures could potentially have altered outcomes.