Source · Prevention of Future Deaths
Katherine Stamp
Ref: 2019-0437
Date: 18 Dec 2019
Coroner: James Healy-Pratt
Area: West Sussex
Responses identified: 0 / 1
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The serious side effects of clozapine, particularly regarding smoking and pneumonia, are under-appreciated by prescribers and not sufficiently detailed in national guidance.
Date
18 Dec 2019
56-day deadline
28 Feb 2020 est.
Responses identified
0 of 1
Coroner's concerns
The serious side effects of clozapine, particularly regarding smoking and pneumonia, are under-appreciated by prescribers and not sufficiently detailed in national guidance.
View full coroner's concerns
The side effects of clozapine, with specific reference to smoking and pneumonia, are under-appreciated Professor jave expert evidence to the Court These side effects may be rare, but they are still important The BNF does not provide sufficient clarity to prescribers about these side-effects
Report sections
Investigation and inquest
A four Article 2 Inquest was completed on 8h November 2019 into the death of Katharine Eva Stamp, without a jury
Circumstances of the death
Miss Stamp died whilst detained under the Mental Health Act as a result of suddent cardiac arrythmia due to hypoxia Hypoxia was the result of a combination of physical health factors Including aspiration pneumonia and probable sleep apnoea linked to obesity, smoking and the effects of clozapine on her respiratory system The lack of any effective national weight-gain monitoring programme for mental health inpatients was casually linked to her obesity and probable apnoea
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action
Copies sent to
Pratt; Assistant Coroner any
Similar PFD reports
Related inquiry recommendations
Report details
- Reference
- 2019-0437
- Date of report
- 18 December 2019
- Coroner
- James Healy-Pratt
- Coroner area
- West Sussex
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 28 Feb 2020 (estimated).
Sent to
- NHS England