Call for better monitoring of clozapine after man’s death

The sister of a schizophrenic man who died from a toxic mix of prescription drugs has called for safer monitoring of the antipsychotic drug clozapine.

William Northcott, known as Wim, died of a cardiac arrest at a care home in Torbay in July 2021 while in the care of the Devon Partnership NHS Trust.

Assistant coroner Louise Wiltshire said clozapine and a combination of other prescribed drugs and amphetamine caused a sudden cardiac arrhythmia in the 39-year-old man.

Following the hearing, the health trust said people attending clozapine clinics would be asked additional questions about potential heart problems.

Since Mr Northcott’s death, his sister Kate Northcott Spall has lobbied medical professionals for policy changes to help clinicians monitor clozapine safely in the future.

His campaign resulted in clozapine being reviewed by the Medicines and Healthcare products Regulatory Agency (MHRA) and the creation of Wim’s Protocol with the Royal College of Psychiatrists, which will launch this year.

The coroner recorded a narrative verdict after a week-long inquest into Mr Northcott’s death at Devon County Hall in Exeter.

He heard that Mr Northcott had been diagnosed with autism, obsessive-compulsive disorder and schizophrenia.

He had been taking clozapine since 2006, with a break in 2011, but started taking it again in 2012. He reportedly suffered side effects such as weight gain and wrist pain.

The inquest focused on the monitoring of clozapine and fluoxetine in the 12 months before Mr Northcott’s death and whether any aspect of the prescribing, dispensing, administration and medication monitoring had caused or contributed to his death.

The investigation’s findings showed “various missed opportunities” in monitoring his physical health and that further blood tests should have been carried out to check clozapine levels.

But Ms Wiltshire found prescription drugs were at levels considered therapeutic.

However, she said she was concerned about the heart monitoring because no one knew Mr Northcott had a significantly enlarged heart. He weighed 590 g (20.8 oz), which is “much higher” than the average male.

Devon Partnership NHS Trust said it immediately responded to concerns raised by the coroner about prescribing clozapine to patients.

“People attending clozapine clinics are already asked a number of wide-ranging questions about their physical and mental health, but, following the survey, they will now be asked additional questions regarding possible heart problems,” he indicated.

Ms Northcott Spall said the memory of her brother’s death was still difficult to think about.

“I couldn’t understand it, I couldn’t understand it and my memory of that day is that it was the most beautiful sunny day and I sat in the darkest part of the garage because I thought what if Wim couldn’t see the sun, and neither could I,” she said.

“I believe if we can make sure these controls are built into the system, specifically for cardiac side effects, we have a chance that Wim’s death will save lives.”

The family’s lawyer, Anna Moore, said: “While nothing will ever compensate Kate and her family for the loss of their beloved brother and son, my client is pleased that the coroner has found that there were lessons to be learned from the gaps in his medication monitoring shown in William’s case.

“Kate would like to see this trust and trusts across the country make urgent changes to their systems and protocols around this and other similar medicines.”