(Image: Jonathan Brady/PA Wire)
A coroner has raised concerns after a 29-year-old man died in North Yorkshire when the levels of the anti-psychotic medication he was taking became toxic in his blood after he quit smoking.
Jack Burton was proscribed Clozapine for paranoid schizophrenia and died while on holiday in Scarborough on October 7, 2025, from a fatal increase of the drug in his blood, a report following his death said.
Coroner Deborah Lakin wrote that Mr Burton, who had been a heavy smoker, was taking the prescribed 525mg Clozapine nightly which was the correct dose when he is smoking.
But the coroner said Mr Burton, from Worcester, had been “regularly advised that any cessation of smoking would increase Clozapine levels” and did not smoke while he was on holiday in Scarborough.
She said Mr Burton stopped smoking tobacco on or before October 4, 2025, and “it is likely that this led to a fatal increase in Clozapine blood levels”.
Ms Lakin said Mr Burton “should have informed his psychiatrist to reduce the amount of Clozapine he was taking” if he stopped or reduced his smoking “as this could cause seizures”.
In a narrative conclusion at an inquest, the coroner found that Mr Burton died of Clozapine toxicity.
Coroner says future deaths could happen unless NHS trust acts
After the inquest, Ms Lakin wrote to the Herefordshire and Worcestershire Health and Care NHS Trust, which cared for Mr Burton, saying she was concerned that future deaths could happen unless action is taken by the trust.
The coroner said there were “inconsistent accounts provided to me by two consultant psychiatrists” during the inquest “about the relevance of reduction in smoking, rather than cessation of smoking”. There was also “no guidance available to doctors on this issue”, Ms Lakin said.
She added that evidence during the inquest “revealed that there is no guidance on any standardised practice available to practitioners relating to asking questions and recording answers given when discussing possible symptoms of side effects of the medication”.
“Practitioners can therefore make no record if no information is provided, which does not indicate whether questions were asked,” she said.
A Herefordshire and Worcestershire Health and Care NHS Trust spokesperson said it has reviewed its “smoking cessation and clozapine monitoring policies” after Mr Burton’s death.
They said the trust has also “developed an action plan to ensure greater consistency across our services”, adding: “We remain committed to learning from the circumstances surrounding Jack’s care and continuously improving our practice.”
“Our thoughts are with Jack’s family, friends, and loved ones at this difficult time,” they said.