Inquest into the Death of Mcdonald, Charles Edward

Contributing factors

• Cessation of smoking upon transfer to prison, which increases clozapine levels (2.5-3 fold)
• Unrestricted access to caffeine-containing beverages in prison compared to restricted access in hospital
• Excessive caffeine consumption after arrival at prison
• Interaction between clozapine and citalopram
• Drug-drug and drug-substance interactions not adequately communicated to prison medical staff
• Lack of awareness among prison medical staff of the significance of smoking cessation and caffeine interactions with clozapine
• Sudden and unexpected cardiac rhythm disturbance without prior clinical warning signs

Coroner's recommendations

1. Patients on clozapine who are returned to Department custody must have a formal handover to the treating psychiatrist at the relevant custodial facility, including comprehensive reports of previous and current clozapine management, all dosage changes, changes in relevant drug and lifestyle factors likely to impact clozapine levels, all clinical screening completed, all clozapine blood levels, and clinical parameters including physical examination findings relevant to clozapine management at time of transfer
2. Department of Corrective Services to educate their medical and mental health staff about specific interactions between clozapine, caffeine, and cessation of smoking not counteracted by nicotine patches
3. Department of Corrective Services to review care of clozapine patients and consider who can usefully ask questions of patients about their caffeine use in the same way patients are currently asked to provide information about their smoking habits