In News

Follow this topic

Bookmark

Record learning outcomes

A 29-year-old patient with paranoid schizophrenia died from clozapine toxicity after stopping smoking while on holiday, a coroner has found.

Worcester resident Jack Burton died on October 7, 2025, while on holiday in North Yorkshire with his family, Worcestershire assistant coroner Deborah Lakin recently reported following the conclusion of an inquest into Mr Burton’s death.

Mr Burton, who was described as a heavy smoker, was prescribed clozapine 525mg which he took nightly – “the correct dose” when smoking, the coroner said.

However, he did not smoke while on holiday, with the inquest having found that he stopped smoking “on or before October 4”.

Tobacco smoke contains hydrocarbons that boost the activity of some liver enzymes, increasing the metabolism of clozapine and thereby reducing plasma levels of the drug.

“If he had stopped or reduced his smoking he should have informed his psychiatrist to reduce the amount of clozapine he was taking, as this could cause seizures,” wrote the coroner, adding that Mr Burton “had been regularly advised that any cessation of smoking would increase clozapine levels”.

The coroner raised concerns that she had received “inconsistent accounts” from two consultant psychiatrists in relation to “the relevance of reduction in smoking rather than cessation of smoking,” which was attributed to a lack of guidance for doctors on this matter.

She said the inquest had also heard that there is “no guidance on any standardised practice available to practitioners relating to asking questions and recording answers given when discussing possible symptoms of side effects of the medication”.

“Practitioners can therefore make no record if no information is provided, which does not indicate whether questions were asked,” she added.

Her report was issued to Herefordshire and Worcestershire Health and Care Trust, which said in its response that its guidelines on this topic “make clear reference” to the impact of both smoking reduction and cessation.

The trust also said that under its standard operating procedure it is “standard practice” to monitor clozapine side effects using the Glasgow Antipsychotic Side-effect Scale (GASS), with outputs from this recorded onto the patient’s electronic health record.

The trust’s chief executive added: “In further response to the concerns raised by the Coroner, the Trust has re-issued both documents to the mental health clinical workforce.

“Follow-up actions will be undertaken to ensure that both newly appointed and existing staff are aware of, and comply with, the guidelines.”

Related: Coroner challenges Streeting on epilepsy medication availability after tragic death

Coroner calls for opioid deprescribing support after fentanyl death