Mohammed Hussain
12 Jul 2023 · Coroner Louise Hunt · Birmingham and Solihull
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of clozapine level monitoring
“there was no clear system for monitoring the actual clozapine and nor clozapine levels”
2. unsafe medication change process
“no safe system to effect medication changes”
3. lack of high clozapine result highlighting
“no system for highlighting high clozapine results in the rio notes”
4. lack of understanding of clozapine monitoring
“lack of understanding of when to measure clozapine levels”
5. lack of escalation system for abnormal clozapine levels
“no system in place to ensure abnormal clozapine levels were escalated and acted upon”
6. inadequate internal investigation process
“initial investigation report did not raise significant issues regarding the monitoring of clozapine”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“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.”
This report
“There was no system for highlighting high clozapine results in the rio notes which are routinely used by all clinicians.”
Responses
2023-0241-Response-Birmingham-and-Solihull-Mental-Health-NHS-Foundation-Trust.pdf ↗· Birmingham and Solihull Mental Health NHS Foundation Trust
Stated action · September 2023
“the Trust has now put into place an urgent learning session along with future planned training and development to ensure staff keep up to date with this and learning is refreshed, alongside other additional support systems that have previously been introduced.”
2023-0241-Response-Medicines-Healthcare-products-Regulatory-Agency.pdf ↗· Department of Health and Social Care
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.”