One such family is that of William Northcott who collapsed aged 39, with cause of death given as “fatal arrhythmia most likely due to prescription drug toxicity”. The drug in question being Clozapine, which Northcott had been on for five years. The Times article provides multiple examples of other families who have suffered similar bereavement, and patients who have suffered deaths linked to the drug.
Despite being subject to stringent controls and patient monitoring, Clozapine has in fact been linked to more than 7,000 deaths since it was licensed to treat schizophrenia in 1990.
The MRHA has issued multiple warnings around its use in recent years but the steady rise in deaths raises questions around the efficacy of the inquest system to effectively communicate coroners’ findings and inform medical practice.
The AI version of the Preventable Deaths Tracker (PDT) was utilised by the Times to analyse cases since 2013 where Clozapine was recorded as a factor, and from data produced by the PDT it was discovered that in 17 of these cases coroners produced Prevention of Future Death (PFD) reports calling for the reform of procedures around the use and monitoring of this medicine.
According to Georgia Richards, around 450 such reports are sent from the coroners to the government and other institutions, including to government ministers every year, but evidence from the PDT shows that this advice is rarely acted upon. She states that “The law requires recipients of such reports to respond with a proposed course of action within 56 days”. However, there is no enforcement of this law, no independent body or system for monitoring PFDs and nobody follows it up if legislatory conditions aren’t met.
The PDT in intrinsic to interrogating inquest data, including coroners’ recommendations and PFDs; to identifying drugs which have significant risk to patient safety and are linked to significant mortality, and to potential failures in the system to action coroner recommendations in healthcare settings. Without the PDT much of this would not be possible.