Inquest into the death of Andrew Stubbs

32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome

Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included: his GP prescribed lithium at an incorrect dose (1250mg instead of 1000mg) for three months and failed to repeat blood tests despite elevated lithium levels and signs of dehydration; hospital teams lacked communication between renal and ICU specialists, failed to conduct risk assessment before escalating dialysis modality, and did not recognise early warning signs (headache) as possible dialysis disequilibrium syndrome rather than lithium toxicity. Clinical lessons include: GPs prescribing lithium require clear guidelines and must verify doses against specialist communications; treating teams managing complex cases across multiple specialties must have explicit communication protocols; rare but serious complications must remain in the differential diagnosis even when other explanations seem dominant.