Articles for tag: assessment, autism, clinical, coroner, diagnosis, GMC, learning disability, medication, psychiatry, regulation, risk

Why the Oliver McGowan Case Still Matters

On 11 November 2016, Thomas Oliver McGowan, an 18-year-old man with epilepsy, mild autism, a mild learning disability, and cerebral palsy, died at Southmead Hospital in Bristol. He had been admitted on 22 October 2016 with uncontrolled seizures. During that admission, he was sedated, intubated, and given olanzapine, an atypical antipsychotic, despite explicit warnings from his family and documented evidence of prior adverse reactions to antipsychotic medication. He developed neuroleptic malignant syndrome (NMS), suffered a catastrophic brain injury, and died. ...

When Capacity Shapes Care: Jarman PFD and RCPsych Findings

The recent Prevention of Future Deaths (PFD) report concerning the death of Tania Louise Jarman highlights once again the profound risks created by chronic shortages in mental health inpatient capacity. The Coroner identified a pattern in which clinical decisions are increasingly shaped by the absence of available beds rather than by the needs of the patient, with potentially fatal consequences. This case does not stand in isolation. The Royal College of Psychiatrists’ membership survey on local capacity provides a detailed, ...

Clozapine-Associated Cardiac Pathologies

Clozapine, an atypical antipsychotic medication, is widely recognised as the most effective treatment for individuals with treatment-resistant schizophrenia (TRS).1 Approved in 1989, its utilisation has grown, particularly for patients who have not responded adequately to other antipsychotic agents.3 Despite its superior therapeutic efficacy, clozapine carries a significant cautionary “black box warning” due to its association with rare but serious adverse effects, most notably agranulocytosis, but also considerable cardiovascular risks.5 It is important to note that, despite these risks, population-level studies ...

Clozapine – including lessons from the Coroner

Clozapine is a unique antipsychotic medication that plays a crucial role in treating severe mental health conditions. It is the only drug proven effective for treatment-resistant schizophrenia, offering hope to patients who have not responded to other treatments. See also: Treatment Resistant Schizophrenia. However, its use comes with strict monitoring requirements due to potential serious side effects, including risks to blood health and the heart. This article explores clozapine’s licenced and unlicenced uses, its historical development, and the protocols for ...

No new lessons here: Retired consultant killed by son who suffered with schizophrenia.

The case of Daniel Harrison, who was convicted of manslaughter by diminished responsibility after killing his father, Dr Nicholas Kim Harrison, highlights significant failings in mental health care management.  The Coroner gave a narrative verdict on 16/04/2024. The homicide had happened in March 2022. [References and sources at the end] Daniel Harrison, diagnosed with paranoid schizophrenia, experienced a deterioration in his condition. He was lost follow-up care from Swansea Bay University Health Board in 2018 after he was removed from a ...