The Southern District Health Board has accepted fault in
its treatment of a Dunedin patient who probably died from
having toxic levels of a drug used to treat schizophrenia.
A coroner's inquest into the death of Dunedin woman Marion
Novak (49), who died in August 2011, heard she most likely
died as a result of having toxic levels of the drug clozapine
in her system. In a postmortem, a toxic level of the drug was
found in her system.
Ms Novak, who had suffered from schizophrenia since the age
of 16, was receiving 800mcg a day - after recently having her
dose reduced from 900mcg - when she died.
Southern District Health Board mental health directorate
medical director James Knight accepted in ''retrospect'' the
levels of clozapine in her system should have been tested
when she was admitted to hospital twice after collapsing in
The collapses were probably a result of seizures, a symptom
of clozapine toxicity, and when in hospital she was found to
have an irregular heartbeat, also linked to toxicity, Dr
He also accepted, after questioning from coroner David
Crerar, the DHB was ''slow off the mark'' in establishing
guidelines for the drug after a man in the DHB's care died in
similar circumstances four months before Ms Novak's death.
''You were a bit late in establishing the guidelines,'' Mr
Dr Knight earlier called clozapine a ''double-edged sword'',
in that it was one of its ''most useful drugs'', but also one
with potentially deadly side effects.
Following the two deaths, the DHB introduced a guideline for
the drug, which included recommending annual testing of
clozapine levels for patients receiving more than 600mcg a
day and testing if there was evidence of toxicity. Carrying
out ECGs was also recommended in certain circumstances.
When questioned by counsel for the Novak family, David
Robinson, about the idea of national standards for clozapine,
Dr Knight said: ''I think it is an excellent idea.''
As it stood, the Ministry of Health did not ''take a lead''
when it came to setting standards and should possibly have
more of a role in doing so.
Pathologist Martha Nicholson accepted her original finding
for cause of death should have used the word ''toxicity''
rather than ''overdose'', as there was no evidence of
The toxic levels found in Ms Novak's system after she died
were instead most likely caused by taking the prescribed
Mr Robinson finished by asking the coroner on behalf of the
family not to use the word ''overdose'' in the cause of
death, to look at increased monitoring of people on
clozapine, national standards for the drug and better liaison
between DHB departments.
Mr Crerar reserved his finding.