Man complained of drug side effects before death

A Blackpool Coroner’s court inquest heard how health professionals had agreed to change the anti-psychotic drug being used by John Cardwell just three days before his dad Henry found him hanging from the banister of their Windsor Road home.

But Blackpool and Fylde coroner Alan Wilson accepted the switch could not have been made before Mr Cardwell’s death on October 6 last year.

The court heard that Mr Cardwell had been diagnosed with paranoid schizophrenia in 1994.

He was under the care of clinician Mukul Sharma at the Woodlands unit in St Anne’s, run by the Fylde and Wyre Complex Care and Treatment Team.

Last April he was prescribed zuclopenthixol to help treat paranoia and delusions.

But a statement by Dr Sharma said this had led to side effects including stiffness to his arms and legs. Mr Cardwell later complained of tremors, restlessness and insomnia.

Changes were made to the frequency he used the medication but the effects continued.

“Mr Cardwell said the side effects were worse with this medication,” said Christine Holmes, a community mental health nurse and Mr Cardwell’s care coordinator.

“We wanted to reduce them and keep a therapeutic level of medication but we did not want to reduce it too much because his symptoms would get worse.”

On Thursday, October 3 it was decided that Mr Cardwell’s medication should be changed.

Two days later he called a weekend crisis team complaining that his side effects were worse and another prescription was delivered to his home.

But he felt no better the following day and was advised to attend an out of hours centre.

His dad took him to A&E at Blackpool Victoria Hospital where he was given diazepam and advised to stop taking his anti-psychotic medication.

Mr Cardwell went to bed after getting home, complaining he was feeling tired. But when his dad returned home from the shops at 3.20pm he found his son hanging from the banister.

The court heard an internal review by Lancashire Care NHS Foundation Trust had concluded that Mr Cardwell should not have been advised to attend an out of hours centre and that this had been clear to the employee concerned.

The review found that Mr Cardwell’s death could not have been predicted but that it may have been linked to his side effects.

Delivering a narrative verdict, Mr Wilson said medication had played no direct part in his death and that he could not be certain Mr Cardwell had intended to take his own life.

“This was not someone who in the recent past had been providing any suggestion to anyone that he intended to harm himself,” he added.