The Southern District Health Board has been criticised for
failing to recognise the risks of clozapine toxicity to a
patient who had twice attended its emergency department
shortly before her death.
Otago-Southland coroner David Crerar found the death of
Marion Gwen Novak (49) in Dunedin on August 25, 2011, was
caused by seizure disorder, clozapine toxicity, and
complications of chronic treatment-resistant schizophrenia.
Ms Novak was taking, as prescribed, 800mg of the
anti-psychotic drug clozapine a day; the dose had been
reduced, in June, from 900mg.
''Regrettably, due to either an inability ... to metabolise
the drug as was expected, or for other reasons, the clozapine
accumulated to a level which proved toxic to her as an
individual with her risk factors,'' Mr Crerar wrote in his
finding, released yesterday.
She had attended Dunedin Hospital's emergency department
twice in June after suspected seizures.
''Marion Novak was admitted to Dunedin Hospital on two
occasions prior to her death. The observations made then
should have placed both the emergency department and the
mental health services on notice. There appears to have been
no cross-checking of patient files between the two branches
of the hospital. The information as to a rapidly developing
serious situation was there, and was there to be seen,'' Mr
''The Southern District Health Board had the opportunity to
provide better care for [Ms Novak] and the evidence has
proved to my satisfaction that systems within the board's
operation did not allow for appropriate messages to be
recorded and disseminated.''
Through a spokesman, health board chief medical officer Dr
David Tulloch said yesterday in response to the written
finding: ''We acknowledge the coroner's findings. We accept
that we could have done better and have apologised to her
family. We are working to ensure that processes are in place
to prevent this from happening again.''
Clozapine is associated with increased risk of seizures at
doses of more than 600mg a day.
Mr Crerar's written finding shows that on the first ED visit,
Ms Novak was found to have abnormal heart activity associated
with clozapine toxicity, but the mental health service was
''In my view, there was more than sufficient evidence for the
Southern District Health Board to have recognised the problem
and taken action to address it,'' Mr Crerar wrote.
After the death, the board adopted clozapine guidelines that
included recommending annual clozapine serum level checks for
patients receiving more than 600mg a day.
Mr Crerar said it was regretful the board had not adopted the
guidelines earlier, given another patient died in March of
that year from clozapine toxicity.
He was also surprised to find that each health board
determined its own guidelines for administering drugs.
''The fact that each board appears forced to create an
independent document seems to be a waste of resource.''
He recommended the Ministry Of Health consider a more
centralised system of clinical advice on such matters.