Call for better drug monitoring 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 antipsychotic drug clozapine.

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

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

Following the hearing, the health trust said people attending clozapine clinics would be asked additional "red-flag" questions about potential cardiac problems.

Since Mr Northcott's death, his sister Kate Northcott Spall has lobbied healthcare professionals for a change in policies to help clinicians safely monitor clozapine in the future.

Her campaigning has resulted in clozapine coming under review by the Medicines and Healthcare products Regulatory Agency (MHRA) and the creation of Wim's Protocol with the Royal College of Psychiatrists, which will be launched this year.

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

It heard 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 had reportedly suffered side effects such as putting on weight and sore wrists.

The inquest considered 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 monitoring of the drugs had caused or contributed to his death.

Findings at the inquest showed "various missed opportunities" in his physical health monitoring and that further blood tests should have been carried out to check clozapine levels.

But Ms Wiltshire found the prescription drugs had been at levels considered to be within therapeutic levels.

However, she said she was concerned about cardiac monitoring as no one had been aware that Mr Northcott had a significantly enlarged heart. It weighed 590g (20.8 oz), which is "much higher" than the average male.

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

"People attending clozapine clinics are already asked a number of wide-ranging questions about their physical and mental health but, following the inquest, they will now be asked additional red-flag questions in relation to potential cardiac problems," it said.

Mrs Northcott Spall said the memory of her brother's death was still hard to think about.

"I couldn't comprehend it, I could not comprehend it and my memory of that day is that it was the most beautiful sunny day and I just sat in the darkest part of the garage because I thought if Wim can't see the sun, nor can I," she said.

"I believe that if we can make sure that those checks are embedded into the system specifically the cardiac side effects, we've got a chance of Wim's death saving lives."

The family's solicitor Anna Moore said: "Whilst nothing can ever compensate Kate and her family for the loss of their much-loved brother and son, my client is pleased that the coroner has found there are lessons to be learned from the gaps in the monitoring of his medication shown in William's case.

"Kate would like to see that this trust and trusts around the country make urgent changes to their systems and protocols regarding this and other similar medications."

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