“(brief summary of matters of concern) 1 The abnormal triglyceride levels in Mr Daniel’s…”

The coroner’s concerns

(brief summary of matters of concern) 1 The abnormal triglyceride levels in Mr Daniel’s blood, whilst reported by the lab, were not escalated by telephone as this was not required by the hospital procedure at the time. I am pleased to note that Hampshire Hospitals Trust have updated their procedures to include telephone escalation of raised triglyceride levels. However the RCA report indicated that the findings in this case should be shared with the Royal College of Pathologists with a request that raised triglyceride levels be added to the RCPath guidelines for telephone action. In information received after the inquest the Hampshire Hospitals Trust advised that they could not tell me whether or not this action has been undertaken. 2. The RCA report identifed that the format of discharge summaries provided to GPs by the ED department needed to be reviewed to ensure that actions to be undertaken by GPs were clearly identified. The results of this were to be audited. Following the inquest I was provided with an audit report. This report dated 13/9/21 revealed that the computer system could not be altered as had been hoped and therefore a change of practice was introduced instead. This required clinicians to document actions in a free text section with appropriate flagging for GPs. 20 cases were audited and only half met the standardised national guidance and 8 lacked a clear diagnosis & details of what was expected from GPs. Hamsphire Hospital Trust have informed me that further actions are being taken to address these deficiencies. However as it is now a year since the RCA report was prepared and over 2 years since Mr Daniel’s death I am concerned that this action is not being taken swiftly given the risks to patients. 3. In relation to the blood tests required under the clozapine guidelines I was informed that Southern Health take the monthly blood tests and run these in the clozapine clinic. However the blood tests required of the annual physical health checks are not taken by the Southern Health staff but rather patients are required to attend phlebotomy services elsewhere for the blood to be taken. I heard evidence during the inquest that Mr Daniels had missed some of these blood test appointments which meant his full tests were not carried out when expected. Clozapine is prescribed only to patients suffering from an enduring mental health condition for whom other medication has not been effective which indicates that they may be at risk of having difficulty managing appointments. Regulation 28 – After Inquest Document Template Updated 30/07/2021 I heard evidence from the consultant psychiatrist responsible for Mr Daniel’s treatment that they were not permitted to take the blood samples and submit them to the local laboratory for testing. I was informed that the Southern Health staff had requested to be able to do this to avoid the patient having to attend another appointment. I have reviewed further information provided after the inquest by the Clinical Director of Southern Health. She has explained that they lack the facilities to complete the full blood tests and they lack the resources to take and deliver samples to the laboratories; noting that no community mental health teams in their trust routinely provide phlebotomy services. She has advised that they are focussed on better communication with primary care and assertive outreach where necessary. I remain concerned that patients on high risk medication, who by the nature of their mental health condition may struggle to attend appointments, are required to arrange or attend separate blood tests. I note that clozapine clinic staff take blood monthly and that the phsyical health reviews are carried out by doctors all of whom should be capable of taking a blood sample for submission to a laboratory.

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, 2023-0346

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0