“Essex Partnership University NHS Foundation Trust (EPUT) (1) EPUT mental health team were…”

The coroner’s concerns

– Essex Partnership University NHS Foundation Trust (EPUT) (1) EPUT mental health team were relying on the clozapine clinic staff to monitor Ms Ahmetaj’s mental health, but this was not the purpose of the clinic. Staff took blood samples and vital signs with a quick chat that took about 5 minutes and were not undertaking a mental state examination. (2) There was confusion about the mental health Trust prescribing dose for Ms Ahmetaj antidepressant medication and an overreliance on discussions with her rather than checking the prescription dose and communication with the GP was delayed. (3) There were issues around communication and escalation within the Trust mental health team. A routine 6-month blood anti-psychotic to check clozapine levels assay was taken on 3 June and the results reported on 7 June were sent to the subtherapeutic blood levels psychiatrist of and antipsychotic showed markedly medication. This subtherapeutic level was not acted upon and was contrary to: a. Ms Ahmetaj insisting she was compliant with her medication b. Ms Ahmetaj did not have any noted risks that would cause interference with her medication. c. Ms Ahmetaj informed EPUT clinicians that: i. On 24 June she thought her medication Clozapine was not working ii. On 27 June she no longer wished to take her prescribed 2 antipsychotic medication , and iii. Did not agree she had Schizophrenia, and iv. wanted to revert to a previous medication Quetiapine. These matters were not escalated to the psychiatrist and Ms Ahmetaj was informed to continue her clozapine and wait for her appointment on 1 July and there was no consideration of the risk of relapse of psychosis. (4) The mental health Trust record-keeping did not contain all relevant information relating to the care and treatment there were omissions relating to symptoms and potential signs of deterioration and compliance with medication. (5) Clozapine constipation was raised as a serious side effect such that there is a Trust policy to manage this matter. This was not dealt with within the Trust for Ms Ahmetaj, and it took two weeks to raise this for the GP to manage. This did not cause or contribute to Ms Ahmetaj’s death however there is a concern for the long delay for other patients. Basildon Car Park Management (6) The car park has a link walkway to residential housing on the penultimate floor from where Resmije Ahmetaj fell. The top floor has mitigation that would prevent a person from jumping/falling but the penultimate floor that has a pedestrian link walkway does not. There is likely to be more pedestrian footfall on the penultimate floor as a consequence and any fall from this height would inevitably be fatal.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0424

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0