“1: Evidence was presented at the inquest to the effect that the interaction between…”
Dated 23 Jul 2015, from the coroner for South Lincolnshire. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 17 Sep 2015. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated23 Jul 2015
- Deadline17 Sep 2015
- Published on judiciary.uk23 Jul 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Medicines and Healthcare products Regulatory Agency | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 17 Sep 2015. A reply may have been sent and not yet published. |
| National Institute for Health and Care Excellence | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 17 Sep 2015. A reply may have been sent and not yet published. |
| Lincolnshire Community Health Services NHS TrustNamed in the report as “Lincolnshire Community Health Services” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 17 Sep 2015. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— 1: Evidence was presented at the inquest to the effect that the interaction between Lisinopril and Spironolactone is well known, and that Lisinopril can precipitate deterioration in a patient's renal function. NICE published guidelines on initiation of Angiotensin converting enzyme inhibitor therapy indicates that patients should be reviewed one to two weeks after initiation of therapy and have their renal function and electrolyte status checked 10 — 14 days after initiation of ACEI therapy. This is re- : iterated in LCHS guidance. The expert evidence at the inquest pointed out that, following a report of a trial in 1999 "The Randomised Aldactone Evaluation Study", there was an increase in the co-prescription of Spironolactone and Lisinopril in heart failure, immediately followed by an increase in hospital admissions and subsequent deaths associated with hyperkalaemia. Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk A R W Forrest tim, rcp, FRcPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire Those to whom | make this report may wish to consider whether or not the current guidance relating to the co-prescription of ACEI drugs, such as Lisinopril, and Spironolactone draws sufficient attention to the need for caution and the need to take a holistic view of the best interests of the patient.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2015-0295
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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