THE delay in admitting a St Saviour’s Hospital patient to the General Hospital following a “medical emergency” was a “lost opportunity” for five days of monitoring and treatment which may have prevented his death, an inquest has heard.
Comments from Professor William Roach, a pathologist for Southampton Hospital, were read out yesterday at a hearing into the death of 60-year-old Michael Herbert Patrick Watkins.
Mr Watkins, the owner of a local gardening businesses, died on 16 August 2021 from acute cardiac failure which followed 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 more than ten years by medication, the inquest heard, 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 from Professor Roach, 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 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 spent the six weeks leading up to his death on 16 August 2021 being moved between St Saviour’s Hospital and the 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 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 reintroduced 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 anti-psychotic medication.
The inquest heard yesterday from one of the doctors working on the hospital ward where Mr Watkins was taken, who admitted that this dose of Clozapine was a “prescribing error”.
In a statement read out by Relief Coroner Sarah Whitby, the doctor admitted that she was “unaware of the need for slow reintroduction of Clozapine at the time” and apologised for the error.
“I have altered my practice as a result of this case,” she added.
