Lack of awareness of fatal side effects of clozapine
Department of Health and Social Care received 2 coroners' reports about this hazard between 13 Nov 2018 and 21 Feb 2025.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“However it appears that many staff are not aware of the significance of this medication particularly when considering potential side-effects and warning signs of deterioration.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action.”
Stated timescale: 8 January 2019
“My officials have made enquiries with a number of bodies on the matter of concern in your report that there should be routine therapeutic blood monitoring (testing of blood plasma levels) in patients who are prescribed clozapine.”
- 6 years 3 months laterIdentical hazardConfidence 0.95 · higha different coroner
“The lack of awareness by a series of clinical staff of the potential fatal side effects of Clozapine”
Original on judiciary.uk ↗ Repeated from the earlier report:staffpotential
Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“The MHRA will engage with stakeholders to ensure the regulatory documents for clozapine meet the needs of both patients and prescribers.”
Stated timescale: this year
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2018 → 2025Luke Worrell6 years 3 months after Thomas Jackson · different coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports highlight that clinical staff lack awareness of Clozapine's significant side‑effects and warning signs. The later report specifies fatal side‑effects while the earlier mentions significance and deterioration signs.
Thomas Jackson · 13 Nov 2018
“However it appears that many staff are not aware of the significance of this medication particularly when considering potential side-effects and warning signs of deterioration.”
Original on judiciary.uk ↗ Luke Worrell · 21 Feb 2025
“The lack of awareness by a series of clinical staff of the potential fatal side effects of Clozapine”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“My officials have made enquiries with a number of bodies on the matter of concern in your report that there should be routine therapeutic blood monitoring (testing of blood plasma levels) in patients who are prescribed clozapine.”
Stated action · timescale: 8 January 2019
“In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action.”
Stated action
“My officials have made enquiries with a number of bodies on the matter of concern in your report that there should be routine therapeutic blood monitoring (testing of blood plasma levels) in patients who are prescribed clozapine.”
Stated action · timescale: this year
“The MHRA will engage with stakeholders to ensure the regulatory documents for clozapine meet the needs of both patients and prescribers.”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2018 → 2025 | 0.84 | 0.24 | Identical · 0.95 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.