On 13.02.14, concluded an inquest into the death of 28 year old Miss Kirabo Kiwanuka who died on 11 June 2011 The jury found the medical cause of death was sudden unexpected death of a patient with bipolar disorder; treated with multiple drugs. The narrative included this statement: Due to the complex nature of neuroleptic malignant syndrome, which can be highly atypical, based on the evidence presented we cannot discount or confirm NMS as a contributory factor to Ms Kiwanuka's death.

Ms Kiwanauka was admitted as an emergency on 23.05.11 and as she was a risk to herself and others from her manic behaviour; she was sectioned under the MHA_ Isaid that her mental state deteriorated, hallucinating, being paranoid and disinhibited. She was treated in secluded confinement; and her parents not permitted to visit for some days. had concerns about the risks and adverse effects of psychotropic medication It was reported that Ms Kirawanuka had an episode of illness with pyrexia and tachycardia in 2009, when admitted with mania, following administration of Acuphase Her creatinine phospokinase was 2215 at the time. She was thought at that time to have a UTI (although the urine test was subsequently sterile), when after transfer to a medical ward, she settled quickly: She also had an idiosyncratic response to Risperidone On this last admission, she developed a persistent tachycardiatShe was begun again on Clopixol Acuphase on 2nd with further injections on 45 and 6th June. She developed a tachypnoea and pyrexia and one of her blood pressure readings showed a of 15mm, although there were gaps in recording her vital signs. Her creatinine kinase was 7074 (6041 on repeat) with a raised AST . Clinically she was thought to have a URTI The psychiatric registrar on call sought advice of a medical registrar on the night before she died,but it was agreed not to transfer_her to medical ITU Royal They drop

Her psychotropics were stopped and clinically her temperature fell and she was in a coherent state of mind the evening before she died of a cardio-respiratory arrest in her sleep. The expert psychiatrist; stated that she had autonomic instability and he could not see how the diagnosis could not be NMS, related to a higher than recommended dose of Promethazine (higher than therapeutic levels at autopsy) and Acuphase: The consultant psychiatrist; said it could not be NMS, especially as there was no rigidity. If she thought it was NMS, she had a low threshold for referral said that rigidity was not necessary and it could be masked by the Procyclidine she was taking Idid not think it could said that the high CK could be due to injections, restraint and mania disagreed, saying that a level of CK of 6000 7000 could not be caused by these things in the absence of serious injury: He could not explain why cases of NMS had been reported with low CKs_ The cardiac pathologist considered sudden cardiac death was likely; the neuropathologist cited the changes in the hippocampal region making an ischaemic more likely than hyperthermia. pathologist who conducted the autopsy was unable to conclude on the balance of probabilities that NMS, oversedation or sudden cardiac death were the cause of death: expert psychiatrist; Isaid that the non referral to a consultant physician at night contributed to her death and that she should have been transferred. NMS has a high mortality up to 33% and required transfer my expert consultant in Accident & Emergency did not consider her clinical condition was serious enough to merit transfer to a medical ward;, judging there not to be autonomic instability, exemplified by non variation in diastolic blood pressure said that psychiatrists were more experienced than physicians in managing NMS_ She expressed reservations and concerns about the safety of transferring someone so sick _ A health care assistant expressed the view that the local medical wards could not handle acutely disturbed patients_ saiduthat medical teams look after delirium and should have looked after Ms Kiwanuka_ did not think that not transferring to a medical ward contributed to death, even though it was acknowledged that she would receive intensive monitoring: She was not examined by a physician when she developed abnormal vital signs_ At the time it appears that there was no facility for a physician from the neighbouring hospital to be called out for a medical opinion, although this is currently explored by SLAM and King's College Hospital:

In my opinion action should be taken to prevent future deaths. The Royal Colleges of Psychiatrists and Physicians are asked to consider the concerns arising from this case and whether , as recommended by my expert psychiatrist; there needs to be joint College guidance on management of acute physical health problems of manic or psychotic patients at risk of sudden death: