Inquest into the death of Ms UT

37y · Female·morbid obesity with dilated cardiomyopathy and obstructive sleep apnoea

Ms UT, a 37-year-old woman with treatment-resistant schizophrenia, died of morbid obesity with dilated cardiomyopathy and obstructive sleep apnoea. She was prescribed clozapine, an effective but potentially cardiotoxic antipsychotic for severe mental illness requiring prolonged psychiatric hospitalization. The central clinical issue was whether clozapine caused her cardiomyopathy. The coroner found insufficient evidence of direct causation, though recognized an indirect link through medication-induced weight gain and obesity. The clinical lesson concerns the complex management of treatment-resistant psychosis: balancing the psychiatric benefits of clozapine against significant metabolic and cardiac risks. The decision to recommence clozapine after initial cessation was appropriate, supported by specialist cardiology consultation, baseline cardiac imaging, and ongoing monitoring. Her physical health complications (obesity, sleep apnoea, hypertension) were recognized and being actively investigated. The coroner made no adverse findings, concluding her mental health care reflected careful and appropriate risk-benefit assessment. The case underscores the need for ongoing surveillance of clozapine's metabolic and cardiac effects, particularly in patients with severe psychiatric illness.