Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of action on high clozapine blood test results
The earlier warning
Ian Allen · 17 Aug 2020 · Louise Hunt, Birmingham and Solihull
“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.”
What was promised
Stated action 1 · response to Ian Allen (17 Aug 2020) · stated 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.”
judiciary.uk/…/2020-0161-Response-from-Dept-Health-and-Social-C…
What recurred
- 12 Jul 2023 · Mohammed Hussain · Louise Hunt · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.