Recurance · prevention of future deaths reports
Pre-inquest brief
Insufficient recognition of clozapine fatal adverse effects
The earlier warning
Katherine Stamp · 18 Dec 2019 · James Healy-Pratt, West Sussex
“The side effects of clozapine, with specific reference to smoking and pneumonia, are under-appreciated”
judiciary.uk/prevention-of-future-death-reports/katherine-stamp
What was promised
No published response from NHS England was found for the earlier reports.
What recurred
- 21 Feb 2025 · Luke Worrell · Andrew Harris · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Katherine Stamp · 18 Dec 2019
“The side effects of clozapine, with specific reference to smoking and pneumonia, are under-appreciated”
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.