Lack of action on high clozapine blood test results
Department of Health and Social Care received 2 coroners' reports about this hazard between 17 Aug 2020 and 12 Jul 2023.
They came from 1 coroner. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“In February 2019 a blood test result confirmed that Mr [name redacted] had a high level of clozapine in his blood. This was not acted upon and no further blood test was taken. The clozapine dose was not adjusted as it should have been.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“the MHRA communicated advice on monitoring blood concentrations of clozapine and other antipsychotics in the August 2020 edition of Drug Safety Update', which is the MHRA's monthly newsletter for healthcare professionals about medicines safety.”
Stated timescale: August 2020
- 2 years 11 months laterClosely relatedConfidence 0.90 · high
“There was no system for highlighting high clozapine results in the rio notes which are routinely used by all clinicians.”
Original on judiciary.uk ↗ Repeated from the earlier report:highclozapine
Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“We will continue to keep the issue of monitoring for clozapine toxicity under close review, including reviewing Yellow Card cases and we will be writing to the marketing authorisation holders to investigate further thresholds for clozapine toxicity.”
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2020 → 2023Mohammed Hussain2 years 11 months after Ian Allen · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight the absence of a reliable system to ensure that elevated clozapine blood test results are recognised and acted upon. The earlier report focuses on escalation of results to consultants, while the later report stresses the need for highlighting high results in clinical notes.
Ian Allen · 17 Aug 2020
“In February 2019 a blood test result confirmed that Mr [name redacted] had a high level of clozapine in his blood. This was not acted upon and no further blood test was taken. The clozapine dose was not adjusted as it should have been.”
Original on judiciary.uk ↗ Mohammed Hussain · 12 Jul 2023
“There was no system for highlighting high clozapine results in the rio notes which are routinely used by all clinicians.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“There is a system in place whereby anomalous results received are escalated to the Consultant, for example, via the Multi-Disciplinary Team meeting, the administrative staff in receipt of paper results or by junior medical staff who have checked electronic investigations; however on this occasion it appears that this failed. We have therefore put in place an additional control whereby our Information Team will send a report to the pharmacy Clozapine Lead of any results >600 so that these can be”
Stated action · timescale: August 2020
“the MHRA communicated advice on monitoring blood concentrations of clozapine and other antipsychotics in the August 2020 edition of Drug Safety Update', which is the MHRA's monthly newsletter for healthcare professionals about medicines safety.”
Stated action
“We will continue to keep the issue of monitoring for clozapine toxicity under close review, including reviewing Yellow Card cases and we will be writing to the marketing authorisation holders to investigate further thresholds for clozapine toxicity.”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2020 → 2023 | 0.70 | 0.39 | Closely related · 0.90 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.