Key Takeaways
- Wendy Gorrie’s lithium level had not been checked for seven months, far exceeding the MedSafe recommendation of testing every three months.
- Signs of lithium toxicity (confusion, tremor, agitation, seizure‑like activity) were present during her hospital stay but were not investigated until she collapsed.
- The coroner found that delayed lithium testing contributed to her deterioration, pneumonia, cognitive impairment and eventual death in the ICU.
- A Serious Adverse Event Review recommended routine lithium checks in the emergency department or medical ward for patients on lithium who present medically unwell.
- Gorrie’s mother urges systemic changes to prevent similar tragedies for other patients on lithium therapy.
Patient Background and Medication Regimen
Wendy Gorrie lived in Levin with her 90‑year‑old mother, Joyce Taylor. She was prescribed a complex psychiatric regimen that included lithium 400 mg daily, venlafaxine 300 mg daily, olanzapine 10 mg at night, and an olanzapine 300 mg depot injection every three weeks. Lithium served as a mood stabiliser and is normally excreted by the kidneys, with therapeutic blood concentrations between 0.6 – 0.8 mmol/L.
Initial Presentation to Hospital
On 16 November 2024, Gorrie was brought by ambulance to Palmerston North Hospital’s Emergency Department after losing her balance while using a walking frame, landing on her left buttock and being unable to bear weight on her right hip. Her mother reported increased confusion compared with baseline. X‑rays showed no fracture, and she was admitted overnight for observation with plans to discharge once she could mobilise.
Early Hospital Course and Missed Opportunities
That evening, staff noted Gorrie was confused, disoriented, unco‑operative and required assistance to stand. She received her usual medications, including the 400 mg lithium dose, and paracetamol for hip pain. The following day she remained mildly confused, shaky and unco‑operative. A rise in creatinine from 85 µmol/L on admission to 112 µmol/L later indicated acute kidney injury secondary to dehydration, yet no lithium level was drawn at this time despite worsening mental status.
Development of Toxicity and Collapse
By 6 December, three weeks into her admission, Gorrie’s condition deteriorated sharply. At 9:45 pm she collapsed, exhibiting a reduced level of consciousness, three minutes of jerky seizure‑like activity, muscle spasms, rigidity, tachycardia, rapid breathing and low oxygen saturations. Blood gases revealed lactic acidosis with hypoxia. After initial resuscitation with oxygen, adrenaline, salbutamol and ipratropium, a lithium level was finally requested at 10 pm and returned a toxic result of 1.90 mmol/L—more than double the upper therapeutic limit.
Coroner’s Findings and Analysis
Coroner Rachael Schmidt‑McCleave released a report stating that multiple opportunities existed for hospital staff to check Gorrie’s lithium levels earlier, given her presenting signs of toxicity. While she could not state with certainty that an earlier test would have prevented death, she concluded that the delay in checking lithium contributed to the progression of collapse, pneumonia and cognitive impairment. The coroner considered it plausible that timely testing could have averted the adverse trajectory.
Guidelines vs Practice
MedSafe advises that lithium levels be monitored approximately every three months for patients on long‑term therapy. Gorrie’s last recorded lithium level before her hospitalization was on 3 May 2024 (0.4 mmol/L, within normal range). Consequently, her level had not been assessed for seven months, a clear deviation from guideline recommendations. The coroner highlighted this gap as a systemic failure that permitted toxic accumulation to go unnoticed.
Family Perspective and Impact
Joyce Taylor described her daughter as a “bubbly, happy, lovely” person whom everyone loved. She explained that she refrained from visiting Gorrie during the final week because she had caught a cold and feared worsening her condition, thereby missing the chance to say goodbye. Taylor’s anguish is channelled into a plea that no other family endure a similar loss, urging health services to implement stricter lithium monitoring protocols.
Clinical Signs of Lithium Toxicity
Lithium toxicity can manifest with muscle weakness, lethargy, impaired balance, lack of coordination, tremor of the extremities and lower jaw, twitching, agitation, altered speech, disorientation, psychosis, drowsiness and seizures. Gorrie exhibited several of these signs—confusion, shakiness, unco‑operativeness, seizure‑like activity and muscle rigidity—yet the clinical team did not connect them to possible lithium excess until the toxic level was finally measured.
Hospital Response and Treatment
After the toxic lithium level was identified, Gorrie was transferred to the intensive care unit. Her renal function and lithium concentrations gradually normalized with supportive care, but she continued to suffer severe agitation and confusion. Despite broad‑spectrum antibiotics for suspected pneumonia, her respiratory status worsened, culminating in bilateral pneumonia. A poor prognosis led to a transition to palliative care, and she died in the ICU on 11 December 2024.
Serious Adverse Event Review (SAER)
Te Whatu Ora Health NZ MidCentral commissioned a SAER, which revealed that Gorrie’s lithium levels in 2023 had been taken roughly every six months. The May 2024 test was the most recent prior to admission. The review concluded that checking her lithium on the day of admission would have been a reasonable clinical action. It recommended sharing the case as a key learning point to ensure timely lithium testing in the emergency department or medical ward for any patient on lithium who presents medically unwell.
Coroner Consultation and Systemic Response
During the coroner’s consultation process, Dr Claire Hardie, Chief Medical Officer of Te Whatu Ora MidCentral, acknowledged the SAER’s recommendation and confirmed that reminders had been issued to general‑medicine senior medical officers about the importance of lithium level monitoring for unwell patients on lithium. An anonymised case review was being organised for educational purposes, reflecting a commitment to translate the tragedy into systemic improvement.
Conclusion and Lessons Learned
Wendy Gorrie’s death underscores the critical importance of adhering to lithium monitoring guidelines, especially when patients exhibit neurological or renal changes. The convergence of missed laboratory checks, overlooked clinical toxicity signs, and delayed intervention created a preventable cascade of harm. Implementing routine lithium assessments in acute settings, educating staff on toxicity symptomatology, and fostering a culture of timely laboratory follow‑up could safeguard other patients on lithium therapy and honour Gorrie’s memory by preventing similar tragedies.