"Prescribing error" saw Hospital patient given 16 times drug dose

Tuesday 30 January 2024

An inquest has heard that a "prescribing error" saw a Hospital patient given 16 times the recommended dose of his antipsychotic medication – before he died following a rare and life-threatening reaction to the drug.

A doctor from the Jersey General Hospital acknowledged the "prescribing error" during comments read out at a hearing into the death of 60-year-old Michael Herbert Patrick Watkins yesterday.

Mr Watkins, the owner of a local gardening businesses, died on 16 August 2021 from acute cardiac failure following neuroleptic malignant syndrome – a rare and life-threatening reaction to antipsychotic drugs characterised by fever, muscle rigidity, and altered mental status.

Mr Watkins had a long history of chronic schizophrenia, but this had been successfully managed for over 10 years by medication, and the 60-year-old was described as a “functional member of society”.

On the first day of the hearing – which is expected to continue throughout the rest of the week – the inquest heard that, in the two months leading up to his death, Mr Watkins’ family suspected that he had stopped taking his antipsychotic medication, Clozapine.

His mental and physical health deteriorated, and Mr Watkins was first admitted to the General Hospital on 7 July 2021, after being referred by his GP for a suspected infection.

The 60-year-old then spent the subsequent six weeks leading up to his death on 16 August 2021 being moved between St Saviour’s Hospital and General Hospital.

The inquest heard that Mr Watkins’ NMS could have been caused by the large dose of the atypical antipsychotic medication Clozapine that he was given upon his first admission to the General Hospital on 7 July.

Expert medical information read out at the inquest explained that, after Clozapine has been stopped for more than 48 hours, the medication has to be re-introduced to the patient in small doses of around 12.5mg.

However, upon admission to the Hospital, Mr Watkins was given his normal 200mg dose of Clozapine – even though family members had made it clear that they suspected he had not been taking the antipsychotic.

The inquest heard yesterday from one of the doctors working on the hospital ward where Mr Watkins was taken intially, who admitted that this 200mg dose of Clozapine was a “prescribing error”.

In a statement read out by Relief Coroner Sarah Whitby, the doctor admitted that she was “unaware for need for slow reintroduction of Clozapine at the time” and apologised for the error.

“I have altered my practise as a result of this case,” she added.

The inquest also heard from Professor William Roach, pathologist who carried out an autopsy on Mr Watkins’ body on 20 August 2021.

Professor Roach concluded that symptoms of NMS – which he described as a “medical emergency” – were evident in Mr Watkins’ case notes from 11 August 2021.

However, the 60-year-old remained in St Saviour’s Hospital and was not admitted to the General Hospital until 16 August 2021.

Professor Roach described this as a “lost opportunity” to instigate five days of monitoring and treatment which he said may have prevented Mr Watkins' ultimate death.

The inquest is expected to continue for the rest of the week.