Source · Prevention of Future Deaths
Christopher Davies
Ref: 2014-0420
Date: 29 Sep 2014
Coroner: John Gittins
Area: North Wales (East & Central)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted insufficient information shared with the patient and family about clozapine interactions with caffeine or smoking cessation, and the warning signs of toxicity. Regular reminders were suggested due to memory issues.
Date
29 Sep 2014
56-day deadline
24 Nov 2014
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner noted insufficient information shared with the patient and family about clozapine interactions with caffeine or smoking cessation, and the warning signs of toxicity. Regular reminders were suggested due to memory issues.
View full coroner's concerns
The father of the Deceased indicated that his son would drink significant amounts of caffeinated drinks and had also cut down on his smoking and that he felt this may have had a bearing on the levels of clozapine in his system and also that the flu like symptoms which his son had prior to his death may have been the result of clozapine toxicity He stated that although his son's clozapine levels were being regularly monitored, at no point was he ever made aware of the possible interaction between caffeine or the cessation/reduction of smoking in relation to clozapine levels, nor was he made aware of the possible warning signs of toxicity.
It was therefore felt that there should be greater emphasis placed on the sharing of this knowledge with users and with staff within the Community Mental Health Team It was also felt that due to memory issues, patients should be regularly reminded of this information.
It was therefore felt that there should be greater emphasis placed on the sharing of this knowledge with users and with staff within the Community Mental Health Team It was also felt that due to memory issues, patients should be regularly reminded of this information.
Report sections
Investigation and inquest
On the 1Oth of February 2014 commenced an investigation into the death of Christopher Paul Davies (DOB 13.02.79, DOD 05.02.2014). The investigation concluded at the end of the inquest on the 26th of September 2014 and recorded a conclusion of Accidental Death with the cause of death being 1(a) Clozapine Poisoning
Circumstances of the death
The Circumstances of the death are that Christopher Paul Davies was found unresponsive at his home address on the 5"h of February 2014 and was verified dead at 16.39 on the same date_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisations have the power to take such action.
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Report details
- Reference
- 2014-0420
- Date of report
- 29 September 2014
- Coroner
- John Gittins
- Coroner area
- North Wales (East & Central)
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: 24 Nov 2014 (stated in the report).
Sent to
- Betsi Cadwaladr University Health Boar