Insufficient recognition of clozapine fatal adverse effects
NHS England received 2 coroners' reports about this hazard between 18 Dec 2019 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.
No published response from NHS England was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“The side effects of clozapine, with specific reference to smoking and pneumonia, are under-appreciated”
Original on judiciary.uk ↗ No published response from NHS England was found for this report.
- 5 years 2 months laterClosely relatedConfidence 0.90 · 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:sideeffectsClozapine
NHS England responded, stating 1 specific action.Response (PDF) ↗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 NHS England
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.
2019 → 2025Luke Worrell5 years 2 months after Katherine Stamp · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient recognition of serious adverse effects associated with clozapine medication.
Katherine Stamp · 18 Dec 2019
“The side effects of clozapine, with specific reference to smoking and pneumonia, are under-appreciated”
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 ↗
No published response from NHS England was found for this report.
No specific action could be extracted with a verified quote.
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 NHS England 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 |
|---|---|---|---|---|
| 2019 → 2025 | 0.72 | 0.33 | Closely related · 0.90 | 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.