“Monitoring clozapine levels: The inquest heard evidence that there was a clear system to…”

The coroner’s concerns

– 1. Monitoring clozapine levels: The inquest heard evidence that there was a clear system to monitor monthly blood test results looking for low white cell count, however there was no clear system for monitoring the actual clozapine and nor clozapine levels. In addition the inquest heard how there was no safe system to communicate high levels of clozapine. 2. Medication changes: After a review on 14/10/22, when a high level of clozapine was noted from a blood test on 03/05/22, the consultant indicated that medication should reduce on the next prescription. This was communicated by email to the care coordinator however this was not read or acted upon. The inquest heard how there was no safe system to effect medication changes. 5 3. How to record high clozapine levels: The clozapine and nor clozapine levels are recorded in the pharmacy section of the records. There was no system for highlighting high clozapine results in the rio notes which are routinely used by all clinicians. 4. Understanding of clozapine: I heard evidence that there was a lack of understanding of when to measure clozapine levels, how to interpret high clozapine levels and then how to respond to a high level. 5. August 2020 Regulation 28 report: I sent a Regulation 28 report in August 2020 (case of Ian Allen) which identified that there was no system in place to ensure abnormal clozapine levels were escalated and acted upon and that there was a lack of understanding of the importance of clozapine monitoring and how frequently levels should be monitored. Given this report there is a concern that the Trust has not learnt from the previous Regulation 28 report. 6. Quality of the internal investigation process: The initial investigation report did not raise significant issues regarding the monitoring of clozapine and importantly whether Mr Hussain did in fact have toxicity. It was only when wrote a report on 26/03/23 (7months after the death) that this issue was highlighted and addressed. This raises a concern about the quality of the internal investigation process and whether it is able to identify central issues in a particular case. 7. Pharmacy resourcing: The inquest heard evidence that processes within the pharmacy were not effective due to a lack of resources.

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, 2023-0241

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