“Birmingham and Solihull Mental Health Foundation Trust 1”
Dated 17 Aug 2020, from the coroner for Birmingham and Solihull. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 26 Oct 2020, after the 56 days for replies had ended (12 Oct 2020). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated17 Aug 2020
- Deadline12 Oct 2020
- Published on judiciary.uk26 Oct 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Birmingham and Solihull Mental Health NHS Foundation TrustNamed in the report as “Birmingham and Solihull Mental Health Foundation Trust” | Response publishedPublished on judiciary.uk in June 2022. |
| Department of Health and Social CareNamed in the report as “Department for Health and Social Care” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
– Birmingham and Solihull Mental Health Foundation Trust 1. In February 2019 a blood test result confirmed that Mr Allen had a high level of clozapine in his blood. This was not acted upon and no further blood test was taken. The clozapine dose was not adjusted as it should have been. 2. There was no system in place at the time to ensure blood test results were escalated to the consultant to ensure action was taken. 3. There was a general lack of understanding at the inquest about the importance of monitoring clozapine levels and how frequently these levels should be monitored. Department of Health 4. I heard evidence at the inquest that there was a general lack of understanding about clozapine monitoring, which blood test to undertake and the general effect this drug can have on patients. I heard evidence that national guidance was required to clearly set out how frequently clozapine levels should be monitored and what type of blood test should be undertaken. 5. Further education is required of Mental Health practitioners on the importance of clozapine monitoring and level adjustment.
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, 2020-0161
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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
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