Luke Worrell
21 Feb 2025 · Coroner Andrew Harris · London South
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of awareness of fatal side effects of Clozapine
“lack of awareness by a series of clinical staff of the potential fatal side effects of Clozapine”
2. inappropriate use of community treatment order
“Inappropriate use of community treatment order, when there was sufficient evidence to keep on a MHA section”
Linked reports
Identical hazardConfidence 0.95 · high
Earlier report
“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.”
This report
“The lack of awareness by a series of clinical staff of the potential fatal side effects of Clozapine”
Closely relatedConfidence 0.90 · high
Earlier report
“The side effects of clozapine, with specific reference to smoking and pneumonia, are under-appreciated”
This report
“The lack of awareness by a series of clinical staff of the potential fatal side effects of Clozapine”
Responses
2025-0123-Response-from-Care-Quality-Commission.pdf ↗· Care Quality Commission
2025-0123-Response-from-DHSC.pdf ↗· Department of Health and Social Care
Stated action · this year
“The MHRA will engage with stakeholders to ensure the regulatory documents for clozapine meet the needs of both patients and prescribers.”
2025-0123-Response-from-MHRA.pdf ↗· Medicines and Healthcare products Regulatory Agency
2025-0123-Response-from-NHS-England.pdf ↗· NHS England