A public inquiry has been demanded into the use of anti-psychotic drugs after an investigation revealed that side-effects from such medication probably played a part in the deaths, in quick succession, of four men on one hospital ward.
Questions have been raised as to whether the deaths, which all took place within seven months, should have been investigated by the Care Quality Commission (CQC).
The charity that runs St Andrew's hospital in Northampton told the CQC it started looking into whether the deaths on its 20-bed Grafton ward were linked shortly after a third patient died in April 2011. A fourth man, William Johnson, 41, a schizophrenic with cerebral palsy, died the following month.
Two of the deaths were not subject to an inquest, and a third was ruled to have been the result of natural causes.
An internal report commissioned by the charity, which has been seen by the Observer, was sent to the CQC in November 2011. The report said postmortems indicated "that the side-effects from the anti-psychotic medication prescribed such as clozapine were possible contributory factors to the death of the four service users".
It recommended that staff be made better aware of the drugs' side-effects. The report said: "Staff dealing with patients who are taking high-dose antipsychotics, polypharmacy [multiple medication] and in particular clozapine should be familiar with the side-effect profile and be alert to the possibility of a deterioration in physical health that may indicate a potentially serious or life-threatening adverse reaction or side-effect."
But the existence of the report came to light only shortly before a second inquest was held last week into Johnson's death. The lawyer for his family asked why it had not been shared with them or the coroner during the original inquest.
"I have never been involved in a case where a report as serious as the Grafton report was never provided to those affected, or even raised with a coroner at an inquest," said Mark McGhee, a partner at Fentons Solicitors. "Four deaths over a seven-month period where there is a potential contributory cause linking the deaths, has to be exceptional, grave and serious, and as such demands a full inquiry of the most public nature."
Johnson died from complications caused by a severe bowel obstruction. The obstruction, which had developed over a number of months, is a recognised side-effect of the antipsychotic medication he had been prescribed.
A second inquest heard that the obstruction was neither identified nor treated and that, as a result, his internal organs shut down, resulting in a painful death. An examination that might have detected the obstruction was not completed, the inquest heard. The coroner said systemic failings contributed to Johnson's death and described the failure to complete the examination at the hospital, where about 600 people are detained under the Mental Health Act, as a "missed opportunity".
"William's death as confirmed by the coroner raises serious issues about the importance of monitoring physical health when very strong psychiatric medication is being prescribed to vulnerable patients," McGhee said. "William was 41 years old when he died. Had his physical health been properly monitored, there is no reason to believe that William would not be here today."
Responses by the CQC under the Freedom of Information Act indicate that it did not believe there was a need to launch its own investigation. It said: "CQC was aware of the service's own reviews following the deaths and, following a meeting with the provider in 2011, we wrote asking for information about their clinical governance and assurance processes with regard to how natural-cause deaths are identified and investigated." It has pledged to continue monitoring St Andrew's and to conduct future unannounced inspections.
But McGhee was dismissive of the response. "Nothing that I have read or been told to date gives me any reason to believe that in the case of these four deaths there has been any appropriate or adequate public scrutiny by the CQC or indeed any any other non-judicial body."
Johnson had been treated at St Andrew's for 18 years and his family said that he had been happy during his time there.
"We would like to extend our sympathies to Bill's family for their loss, and express our great sadness that their son died while in our care." a spokeswoman for St Andrew's said. "We are very sorry for all the distress they have suffered."
The spokeswoman added that Johnson's death had been very upsetting for his carers. "We care for patients with very complex conditions and everyone who works in the charity aims to provide the highest standards of care." (Source : http://www.theguardian.com/society/2013/jul/07/call-inquiry-deaths-psychiatric-hospital)