Inquest: Artist died after suffering rare side effect of drug

Hackney artist Sophie O’Neill, 37, who died in December 2019. Photograph: O’Neill family, provided by Leigh Day solicitors. Free for use by partners of BBC news wire service

The  grieving mother of a Hackney artist who died after suffering a rare side effect to a drug she was taking for her mental health condition said she believes her daughter’s death could have been prevented.

Opportunities were missed to pick up signs that Hackney artist Sophie O’Neill was suffering side effects from a drug she was taking to manage a mental health condition, a jury inquest has said.

Sophie O’Neill, who was diagnosed with schizophrenia in 2003 died after suffering the heart condition myocarditis and liver failure from the anti-psychotic drug clozapine she had been taking.

She was being treated at the City and Hackney Mental Health Unit run by the East London NHS Foundation Trust in December 2019 after suffering a relapse, and it was thought she had missed two days doses of the medication.

She collapsed within an hour of taking her last dose of clozapine on 20 December. Her oxygen levels dropped rapidly, and she went into cardiac arrest.

Despite attempts to resuscitate her at the nearby Homerton Hospital, the 37-year-old artist died on 21 December 2019.

Her mother Dorothea, who had to push for an investigation and inquest, said: “We urge anyone with a loved one in a psychiatric hospital or facility to fully involve themselves in their care, and where something feels wrong to call out to staff assertively and ask to see the evidence that all basic care is being undertaken.”

Her daughter trained at the prestigious Central St Martin’s School of Art and was a leading light at Hackney-based charity Core Arts.

Consultant psychiatrist Fatema Ibrahim said Ms O’Neill was withdrawn and very unwell when she was admitted to the unit, and the plan was to restart her on a lower dose of clozapine and gradually increase it.

Observations of her vital signs were taken four times daily, including before and after clozapine doses.

The drug is only provided by hospitals and the inquest heard patients taking it are closely monitored by an external company.

Dr Ibrahim said the drug is used when other medications have failed.

Dr Ibrahim had treated Ms O’Neill in 2014 and 2018 when she had suffered similar relapses. She had taken clozapine for nearly a decade and had missed it on several occasions.

Patients’ blood counts and white blood cells must be monitored for the first 18 weeks of taking the drug.

The rare risk of myocarditis is most likely in the first two months, but it can also happen after the drug is restarted.

The inquest heard the link was set out in the East London NHS Foundation Trust’s clozapine policy.

It states that a high heart rate of above 120 bpm, or a long-standing high heart rate over 100 bpm could be a risk marker for clozapine-induced myocarditis. The policy states that should this occur, it should be investigated and the drug stopped if myocarditis is suspected.

The jury at the inquest at Bow coroners’ court highlighted issues of staff communication and a lack of action following observations before and after administering clozapine which “contributed to the loss of a chance” to prevent Ms O’Neill’s death.

The jury found that actions and observations were not adequately communicated or escalated to the consultant primarily responsible for Sophie’s care, and highlighted a lack of action after observations in the two days before she died.

The inquest heard Ms O’Neill’s heart rate was over 100 bpm in many her observations, and over 120 bpm on six occasions.

Clozapine was stopped only once on advice from an on-call doctor during the night of 18 December. It was then re-started after her pulse rate came down.

Her highest heart rate reading was 141 bpm on 20 December, just before her final dose of clozapine.

Blood tests showed that levels of CRP, a protein made by the liver in response to inflammation, were raised from 17 December but did not prompt suspicion of myocarditis, the inquest heard.

An ECG test was never done, however a blood test for troponin, which is an indicator of heart damage, was done once on 15 December.

Dr Ibrahim said she had not been made aware of Sophie’s abnormal observations or raised CRP levels by junior doctors or nursing staff and was not made aware when on-call doctors were involved with Sophie’s care overnight on 18 December.

If she had she would have asked for further investigation.

Junior doctors believed Sophie was suffering a respiratory tract infection, the inquest was told.

Ms O’Neill’s mother Dorothea, who visited regularly, raised concerns that her daughter seemed “incredibly sleepy” the day before she died.

She said her daughter had swollen ankles but this was put  down to a lack of movement.  A cardiologist told the inquest that fatigue and swollen ankles can be  symptoms of heart failure.

Mrs O’Neill also highlighted the monitoring of food and liquid and the inquest heard her daughter had to be encouraged to drink. Ms O’Neill was treated as a day patient at the Homerton for dehydration on 18 December.

Her mother said she had to escalate concerns about her daughter’s deteriorating physical health.

Speaking after the inquest Mrs O’Neill said: “If repeated and avoidable errors had not been made by the Trust, Sophie’s death might have been prevented.

“These include not carrying out basic handovers between staff, not escalating National Early Warning Scores in line with national guidance, not following clozapine guidelines, and not ensuring that a vulnerable patient stayed hydrated.

“Had Sophie’s care been adequate, we believe she might still be here today. We hope that the Trust soon takes and evidences the actions they have promised in order to prevent future deaths.”

Assistant Coroner Sarah Bourke said she had concerns about the recording of vital sign observations and escalating abnormal observations.

The coroner said changes need to be made to East London NHS Foundation Trust’s policies on clozapine, vital signs  and care of mental health patients’ physical health.

In a statement East London NHS Foundation Trust said: “Our Trust expresses its deepest sympathies to the family and friends of Sophie O’Neill. We acknowledge the findings from the inquest and remain committed to actioning issues of concern outlined.

“As a trust, we recognise the benefits and risks of clozapine and will continue to ensure that our staff are fully aware of these.”