Carmel Sparke A GP prescribed the wrong lithium dose to a patient despite receiving a hospital discharge summary and reports with the correct dose , an inquest has heard .
Andrew Stubbs died three months later from dialysis disequilibrium syndrome ( DDS ), a rare complication of dialysis to treat severe lithium toxicity and kidney failure .
The Coroners Court of NSW was told that the 32-year-old ’ s schizoaffective disorder had been successfully treated with lithium since 2017 .
He was admitted to Campbelltown Hospital for treatment in 2019 and then discharged with a plan to reduce his dose from 1250mg per day to 1000mg . This was subsequently done
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while he was under the care of a community mental health team .
In April 2020 , Mr Stubbs was then discharged into the care of his GP , with whom he had consulted over the previous four years .
“ Andrew told [ the GP ] that he was on a dose of 500mg lithium in the morning and 750mg lithium at night ( 1250mg per day ),” NSW deputy state coroner David O ’ Neil wrote in his findings .
“[ The doctor ] considered Andrew to be a rational historian who was proactive about his own health . He therefore felt it was reasonable to accept Andrew ’ s account at the time .
“ He recorded the dose in Andrew ’ s medical record .”
The GP said he had developed a
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good rapport with Mr Stubbs over the years ; however , he had been given limited guidance on prescribing lithium and only recalled prescribing the drug to two or three other patients .
As part of the clinical handover , the
‘ It had not clicked that the dose on the documents was different .’
GP was sent four documents , including a discharge summary , listing the correct dose before his conversation with Mr Stubbs .
“ In evidence , he stated it had not ‘ clicked ’ that the dose on these
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documents was different , and he had overlooked it ,” the coroner said .
“ He accepted he had not ‘ doubleor triple-checked ’ ... and that he should have done so .”
Blood tests taken the following month showed that Mr Stubbs ’ lithium levels were above therapeutic levels .
But repeat blood tests were not arranged , the coroner said .
Mr Stubbs was eventually taken to Bowral Hospital , which found he had a toxic / fatal level of lithium ( 4.5mmol / L ).
On transfer to Campbelltown Hospital , he was initially administered continuous venovenous haemodiafiltration in the ICU before being transferred to the renal unit for intermittent haemodialysis . Both carried risks of DDS .
By the following evening , Mr Stubbs
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was complaining of severe headaches , confusion , drowsiness and vomiting — asking nursing staff to “ just let me die ”.
After he lost consciousness a few hours later , a CT scan and then an angiogram of Mr Stubbs ’ brain showed his condition was non-survivable , with diffuse cerebral oedema , consistent with raised intracranial pressure , and herniation of the cerebellar tonsils .
In findings published last month , the coroner rejected the GP ’ s declaration he had had limited guidance for prescribing lithium .
“ As [ he ] had accepted the responsibility of prescribing lithium , it was incumbent upon him to seek support and advice as needed to prescribe it safely ,” he wrote .
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