Liane Davenport

26th January 2021  

Dr N Shaw 
HM Coroner for County of Cumbria 
Fairfield  
Station Road 
Cockermouth 
Cumbria 
CA13 9PT 

Executive Suite 
1st Floor  
St Nicholas Hospital 
Jubilee Road 
Gosforth 
Newcastle upon Tyne 
NE3 3XT 

Dear Dr Shaw 

RE: 

Inquest into the death of Liane Davenport 
Regulation 28 Report to Prevent Future Deaths Response 

We write in response to your Regulation 28 Report dated 10th October 2019 following your 
investigation into the death of Liane Davenport. This response has been prepared by 
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (“The Trust”) and 
addresses the concerns as set out by you.  

As you are aware Mental Health Services at the time of Ms Davenport’s death were provided 
by Cumbria Partnership NHSFT. As of 1st October 2019, those services are now provided by 
the Trust.  

Please note that we have only recently been made aware of this Regulation 28 Report as it 
was not addressed to the Trust (this was initially sent to Cumbria Partnership NHS 
Foundation Trust (‘CPFT’) and has recently been sent to the Trust) which is why there has 
been a significant delay in providing a response.  

The issue you raised within your regulation 28 report is as follows:  

Should monitoring of blood levels of powerful antipsychotics be considered and 
recommended for patients on long term high dose treatment, particularly as they 
become older and more frail.  

As far as we are aware, there was no indication during the course of the inquest that you 
were considering a Regulation 28 report in relation to the above and the evidence given by 

confirmed that Ms Davenport was being monitored by the physical health team 

within the CMHART in response to the high doses of medications that she was taking.   

Response  

The Trust recognises the concerns that have been raised with regards to the monitoring of 
blood levels of patients on long term high dose treatment and in particular, powerful 
antipsychotic medication.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 An investigation was carried out by CPFT (prior to its merger with the Trust) which we 
understand was provided to HM Coroner in advance of the inquest hearing. This 
investigation evidenced that Ms Davenport’s physical health was monitored in accordance 
CPFT guidance at the time i.e. Ms Davenport attended CPFT for regular monitoring to 
identify any adverse physical health effects from the antipsychotic medication she was 
prescribed. This basic physical health monitoring included:  

1.  Monitoring and recording any side effects of treatment;  
2.  Monitoring weight;  
3.  Measuring weight circumference annually;  
4.  Taking pulse and blood pressure annually;  
5.  Fasting blood glucose levels, HbA1c and blood lipid levels annually;  
6.  ECG conducted annually;  
7.  Advice provided on healthy lifestyle intervention; and  
8.  Ms Davenport to attend annual physical health review with the CMHART Physical 

Health Clinic.  

It is also noted in the investigation report that there was evidence of good communication 
with Ms Davenport’s GP between 2008 and December 2019 with regard to physical health 
monitoring and high dose antipsychotic treatment (‘HDAT’) and CPFT CMHART staff 
proactively chased up missed physical health clinic appointments by conducting home visits 
and escorting the patient to the appointments.  

Whilst Ms Davenport’s physical health was monitored as specified above, we note that she 
could have qualified for more regular monitoring of her physical health as she was on HDAT, 
in line with RCPsych guidance. We do, however, understand that the HDAT policy was not 
approved in CPFT until approximately 4 months after Ms Davenport’s death (1st March 2019) 
and as such, the relevant clinicians were acting in accordance with CPFT guidance at the 
time. In addition, we note that, in any event, neither basic nor HDAT monitoring would have 
involved the monitoring of plasma levels of the specific antipsychotic medication that Ms 
Davenport was on (Quetiapine and Amusulpiride) and this mode of investigation is not 
recommended in routine clinical practice by NICE, RCPsych or by the British Association of 
Psychopharmacology as the assessment of antipsychotic intolerance (or ‘toxicity’) is a 
clinical finding primarily associated with worsening side effects such as extrapyramidal 
effects, sedation, confusion and ECG changes. 

In light of the above, the Trust considers that the care provided to Ms Davenport particularly 
in relation to her physical health monitoring was appropriate in the circumstances. However, 
to provide assurances to HM Coroner, the Trust has reviewed the measures which are in 
place to ensure that a patient’s physical health is sufficiently monitored when they are on 
HDAT for prolonged periods of time.  

We have attached the Trust policy on HDAT monitoring (alongside the Trust Guidance to be 
read alongside this policy) for ease of reference which details the additional monitoring 
requirements for adult patients prescribed HDAT.  

To summarise, the additional monitoring requirements/tests/measurements are as follows: 

•  ECG; 
•  Urea and electrolytes; 
•  Liver function;  

 
 
 
 
 
 
 
 
 
 •  Prolactin;  
•  Blood pressure and pulse (sitting/lying/standing);  
•  Temperature;  
•  Clinical signs of hydration;  
•  Glucose regulation;  
•  Review of side effects including a specific review for movement disorder; and  
•  Review of PRN medication.  

The Trust policy sets out the importance of each investigation/test and the frequency for 
conducting each investigation/test. You will note that the additional monitoring requirements 
do not include the monitoring of blood levels in accordance with the relevant national 
guidance as set out above.  

We hope that the information provided offers you the necessary assurances that the Trust 
have invested time, effort and resource into investigating the issues you have highlighted 
with a view to improving patient care and safety and reducing the risk of any adverse 
incidents or outcome in the future.  

Should you wish to discuss any of the above further, please contact 

Yours sincerely 

Executive Director of Nursing and Chief Operating Officer