“The lack of awareness by a series of clinical staff of the potential fatal side effects…”
Dated 21 Feb 2025, from the coroner for South London. Sent to 5 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
Deadline passedReplies were due by 18 Apr 2025. A reply may have been sent and not yet published.
Organisations 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.
- Report dated21 Feb 2025
- Deadline18 Apr 2025
- Published on judiciary.uk7 Mar 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Medicines and Healthcare products Regulatory AgencyNamed in the report as “MHRA” | Response publishedPublished on judiciary.uk in March 2025. |
| NHS England | Response publishedPublished on judiciary.uk in March 2025. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in March 2025. |
| Royal College of Psychiatrists | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 18 Apr 2025. A reply may have been sent and not yet published. |
| Care Quality Commission | Response publishedPublished on judiciary.uk in March 2025. |
The coroner’s concerns
– 1. The lack of awareness by a series of clinical staff of the potential fatal side effects of Clozapine 2. Inappropriate use of community treatment order, when there was sufficient evidence to keep on a MHA section.
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, 2025-0123
- 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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