“During the inquest I heard evidence that there should be regular repetition of…”

The coroner’s concerns

– (1) During the inquest I heard evidence that there should be regular repetition of information to patients suffering from treatment resistant schizophrenia about the risks and red flags associated with the side effects of taking Clozapine. Since William's death Devon Partnership NHS Trust has set up Clozapine clinics which provide the opportunity for staff who are familiar with the side effects associated with Clozapine to discuss these with patients attending for their monthly phlebotomy appointments (required for the purpose of monitoring their white blood cell count). At these appointments healthcare professionals will specifically ask patients about their smoking habit, caffeine intake, bowel movements, hypersalivation, sedation, nausea, incontinence, heartburn, infection, and medication changes, in addition to open questions about any other side effects a patient might be experiencing. I am also assured that Devon Partnership NHS Trust will be including additional questions to be discussed at this appointment surrounding recent physical illnesses, palpitations, chest pain, breathlessness and dizziness. Currently around 60% of the cohort of patients prescribed Clozapine who are under the care of Devon Partnership Trust have access to these clinics. The other 40% will attend their GP surgery for their monthly Clozapine phlebotomy service. The phlebotomy service provided at a GP practice is usually an appointment with a non-qualified member of staff, who will not have been specifically trained in the side effects of Clozapine. I am therefore concerned that the level of care provided to patients attending Clozapine clinics on a monthly basis, is likely to be superior from the care provided to those patients who attend their GP practice. In particular, I am concerned that any discussion 2 and repetition of information surrounding reg flags and side effects associated with Clozapine, and advice about when to seek medical attention, will be significantly more limited for those patients attending their GP practice than for those attending the monthly Clozapine clinics. I am also concerned that this limitation is likely to extend further than the 40% of patients in receipt of Clozapine under the care of Devon Partnership NHS Trust and that this may be a national issue. (2) At post mortem examination William was found to have a significantly enlarged heart and left ventricular hypertrophy. This was not known to those caring for William in life. Clozapine is a cardiotoxic drug, and is often used in conjunction with other drugs which may also have a cardiotoxic effect. The risk of myocarditis is reasonably well explained in Devon Partnership NHS Trust's policy documentation, but there is less of a focus on cardiomyopathies which would include left ventricular hypertrophy. I understand that the Trust's guidance is based on national guidance. Annual ECGs are required for patients prescribed Clozapine and questions about cardiac function will now be asked at monthly Clozapine clinics. However, I understand that ECGs are not a diagnostic tool used to assist in the diagnosis of cardiomyopathies such as left ventricular hypertrophy and that left ventricular hypertrophy can be asymptomatic. I also understand that an echocardiogram may be able to identify such cardiomyopathies, but that this is not currently required on initiation of Clozapine or routinely at any other time whilst a patient is taking Clozapine. I am concerned that these cardiomyopathies could therefore go undetected in patients prescribed Clozapine and leave them at unknown increased risk of fatal cardiac arrythmias, as occurred in William's case. Given that the Trust's guidance is based on national guidance I am concerned this may be a national issue. (3) It is clear that patients suffering with treatment resistant schizophrenia are complex, and as such there are often a number of different agencies involved in an individual's care. In addition, there are often multiple members of the same team involved in an individual's care. During the inquest it became clear that, at times, communication of important issues was not as clear as it should have been. I note that Devon Partnership NHS Trust has significant training available for its staff and other agencies it engages with in relation to patients who are prescribed Clozapine. However, it would be of great assistance to understand what Devon Partnership NHS Trust is doing to ensure that optimum communication of key information is achieved within the community mental health team, and when dealing with its other agencies involved in a patient's care.

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, 2025-0069

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