Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of awareness of fatal side effects of clozapine
The earlier warning
Thomas Jackson · 13 Nov 2018 · Andrew Haigh, Staffordshire (South)
“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.”
judiciary.uk/prevention-of-future-death-reports/thomas-jackson
What was promised
Stated action 1 · response to Thomas Jackson (13 Nov 2018) · stated 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 2 · response to Thomas Jackson (13 Nov 2018) · stated timescale: none stated
“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.”
What recurred
- 21 Feb 2025 · Luke Worrell · Andrew Harris · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · Luke Worrell · 21 Feb 2025
“The lack of awareness by a series of clinical staff of the potential fatal side effects of Clozapine”
What happened next
No web check of the stated actions has been published for this chain.