HEALTH trusts say lessons have been learnt from the death of a psychiatric patient who died from an overdose of prescribed drugs.

Peter Harper, 62, of Grassholme Place, Newton Aycliffe, County Durham, had three times the recommended level of lithium in his blood, a mood stabilising drug which he had taken for more than 20 years, an inquest at Bishop Auckland Hospital heard yesterday.

Deputy Durham coroner Brenda Davidson recorded a verdict of misadventure after hearing that, although Mr Harper's lithium levels were monitored, action was not always taken and possible symptoms of the overdose were not immediately recognised in the days before his death last July.

Denise Wyatt, community services manager for the Tees, Esk and Wear Valley NHS Trust, said Mr Harper was being treated by his GP and a consultant, and was taking 12 other medicines.

She said there were informal discussions between the two doctors about his lithium levels, but these were not recorded.

She said: "The monitoring of the lithium levels was not as robust as it could have been."

Mr Harper had become dishevelled and confused in the days before his death and his mental health had deteriorated.

When he was admitted to hospital, his lithium levels were 2.4, the recommended level being 0.8.

National Institute of Clinical Excellence lithium guidelines changed soon after Mr Harper died.

A joint statement by the NHS trust and County Durham Primary Care Trust said: "Following Mr Harper's death, we carried out a thorough investigation into his care and have learnt some important lessons. It was evident from the review that there were some things that we could have done differently.

"Since then, the primary care trust and the Tees, Esk and Wear Valley trust have been working to strengthen procedures and improve communications between health care professionals.

"This is a sad case and it is essential that we now use what we've learnt to help us prevent something similar happening again."