Probe sought into death of four men at hospital

Guardian News and Media/LondonA 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.