Safety event	Relapse of service user with bipolar disorder after a long period of stability, caused by sudden discontinuation of lithium carbonate medication.
Outcome(s)	Psychiatric hospitalization, severe depressive episode and minor accidental physical injuries due to risky behaviours in manic episode.
Description of contributory factors	Due to the COVID‐19 pandemic, guidance was issued recommending that lithium monitoring intervals were to be increased from 6 up to 9 months for stable patients (April 2020). Service user had been responding well to lithium carbonate (Priadel® brand) for 2 years whilst under the care of Community Mental Health Team. Six‐monthly routine physical monitoring indicated no abnormalities (blood levels within therapeutic range, no problems with renal or thyroid function). Due to stability on medication regimen, service user was discharged from secondary care for continued monitoring in primary care. Service user informed by care coordinator that their GP practice would contact them directly when required to arrange a follow‐up consultation in primary care (July 2020). No documentation of secondary care discharge letter in GP records. Therefore, Community Mental Health Team still presumed to be responsible for medication and physical health monitoring. No attempt made to contact service user (July 2020). Essential Pharma Ltd. announced a discontinuation of Priadel® from April 2021 onwards (September 2020). GP practice began to contact service users prescribed with Priadel® to arrange medication reviews and to plan transition to a different brand of lithium. Service users only contacted if records indicate that there is no current Community Mental Health Team care package in place. No check made on whether secondary care services were managing these transitions for their caseloads. No attempt made to contact service user (September 2020). Service user running low on their medication supply and was delayed in submitting repeat prescription to pharmacy (February 2021). Pharmacy supplies of Priadel® had already run out when service user submitted repeat prescription form (March 2021). Pharmacist explained to service user about discontinuation of Priadel® brand, recommended alerting their GP and requesting prescription review. Pharmacist failed to advise service user to contact NHS 111 for advice or emergency prescription. No check of how many tablets service user had left (March 2021). Service user abruptly ran out of medication before contact could be made with GP. Sudden discontinuation led to acute episode of mania resulting in hospitalization (March 2021).