Inquest into the Death of Samuel Edward ASHBY

Contributing factors

• Smoking cessation leading to increased clozapine serum levels
• Clozapine-induced sedation and hypersalivation
• Untreated or inadequately managed obstructive sleep apnoea
• Poor maintenance of CPAP machine
• Elevated C-reactive protein not managed according to clozapine guidelines
• Inadequate monitoring of clozapine levels when smoking status changed
• Cognitive impairment affecting ability to maintain medical devices

Coroner's recommendations

1. Implement alerts on electronic health records (EcHO) for all prisoners prescribed clozapine to ensure health centre staff are aware of the prescription and can monitor for smoking cessation effects
2. Educate health staff on the significant effects of smoking cessation on clozapine serum levels and the need for dose reductions (10-40%) when patients cease smoking
3. Ensure adherence to clozapine monitoring guidelines, particularly regarding C-reactive protein levels (CRP >100 mg/L should result in cessation of clozapine and physician assessment; CRP 50-100 mg/L requires ECG and daily blood tests)
4. Implement mandatory regular reviews and inspection of CPAP machines for prisoners requiring them, with at least 12-monthly checks
5. Provide structured support and education to prisoners with cognitive impairment regarding the use and maintenance of medical devices such as CPAP machines
6. Establish systems to ensure that prisoners with mental health conditions and cognitive impairment receive direct supervision and assistance with maintaining the cleanliness of CPAP masks and devices