Resmije Ahmetaj

Essex Coroners Service 
Seax House 
Victoria Road South 
Chelmsford 
Essex 
CM1 1QH 

FAO John Guthrie 

Dear Sirs 

6th October 2025 

RE: RESMIJE AHMETAJ (MERITA BRAHIMI) INQUEST 

Thank you for providing the Coroner’s Report dated 12th August 2025 in respect of Resmije Ahmetaj. 

In response to the Coroner’s opinion concerning actions BTCM Limited can take, we have approached 
contractors with a view to installing mitigation measures at the car park level concerned (pedestrian 
link walkway). The mitigation measures will be to cover up the stairways using mesh and to extend 
the railings 1m either side of the stairwells from Level 10 to Level 4 on both sides of the car park.  

The quotes were due to be returned on Friday 3rd October 2025, but there is a delay in receiving the 
third and final quote. We expect to have this in the next working day or so, and hope to be in a position 
to instruct a contractor to proceed immediately, subject to lead times etc. 
We will provide an update on timings once these are known. 

Yours faithfully 

Director 

BTCM Ltd, Basildon Market Service Building, Westgate, Basildon, Essex. SS14 1FW 
Telephone: 01268 530697 

Registered Office: Level 7 One Bartholomew Close, Barts Square, London. EC1A 7BL. Registered in England No. 02074221

06 October 2025 

Private and Confidential 
Ms Sonia Hayes  
HM Area Coroner for Essex 
Coroner’s Office 
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH 

Dear Ms Hayes, 

Chief Executive Office 
The Lodge 
Lodge Approach 
Wickford 
Essex 
SS11 7XX 

Resmije Ahmetaj otherwise known as Merita Brahimi (RIP) 

I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 
5,  of  the  Coroners  and  Justice  Act  2009  and  regulations  28  and  29  of  the  Coroners 
(Investigations) Regulations 2013, dated 12 August 2025 in respect of the above, which was 
issued to the Trust and Basildon Car Park Management following the inquest into the death of 
Ms Brahimi. 

I would like to begin by extending my deepest condolences to Ms Brahimi’s family. The Trust 
sympathises with their very sad loss.   

The matters of concern as noted within the Regulation 28 Report have been carefully reviewed 
and noted.  I will now respond in full to these concerns in respect of those concerning the Trust, 
in  the  hope  that  this  provides  both  yourself  and  Ms  Brahimi’s  family  with  comprehensive 
assurance of changes that have been made and already underway to address the concerns 
you have raised.  

Concern 1) EPUT mental health team were relying on the clozapine clinic staff to monitor Ms 
Ahmetaj’s mental health, but this was not the purpose of the clinic. Staff took blood samples 
and vital signs with a quick chat that took about 5 minutes and were not undertaking a mental 
state examination. 

Response: 

It is important to appreciate that the Clozapine clinic is not a standalone service but part of 
the wider mental health team.  Personnel who run the clinic are Care Coordinators, who hold 
their own caseload and are part of the service Multi-Disciplinary Team (MDT).   

Where possible patients seen through the Clozapine clinic are assigned a Care Coordinator 
who forms part of the Clozapine clinic staff in order to ensure continuity of care. As such,   
Ms Brahimi’s Care Coordinator was part of the Clozapine clinic and provided support both in 
the Clozapine Clinic and in her role as Care Coordinator outside of the clinic. 

A protocol for clozapine clinics forms part of the Trust’s Formulary and Prescribing 
Guidelines which sets out the responsibilities of the various parties to this support pathway 
and provides the practicalities of running these clinics.  The purpose of these clinics is 

 primarily to enable the undertaking of the mandatory blood testing required for continued 
supply of clozapine.  

The Trust ethos is to make every contact count and each contact is therefore an opportunity 
to interact with a patient and for staff to monitor a patient’s mental state, which is also 
undertaken by the care co-ordinators as part of their role within this clinic.   

Patients attend clozapine clinic for the duration they are prescribed the medication which 
may be many years; during which staff are able to build relationships with the patients over 
time.  Formal mental health assessment is only one method for assessing a patient’s mental 
state and staff are cognisant that patients can prepare answers when they become familiar 
with an assessment tool.  There is considerable value in the informal discussions used at the 
clinic to gain insight into a patient’s mental health.  If there are any indicators of concern 
these are escalated to the Consultant and / or the assigned Care Coordinator for onward 
clinical management. 

We would like to assure the Court and the family that this concern has been shared with the 
mental health team manager and team in order that review and reflection can be carried out 
in respect of this PFD and the Court findings in this case.  

Concern 2) There was confusion about the mental health Trust prescribing dose for 
Ms Brahimi’s antidepressant medication and an overreliance on discussions with her rather 
than checking the prescription dose and communication with the GP was delayed. 

Response:  

In mental health practice, medication non-adherence and patient-led dose adjustments are 
common.  Patients may alter their prescribed regime for example, by taking half a tablet 
instead of the full dose depending on how they feel.  This can result in discrepancies 
between what is prescribed, what is dispensed, and what the patient reports.  Such 
challenges are well recognised in the wider clinical literature, and clinicians are often 
required to navigate uncertainty between prescribed and actual medication use. 

In this case, during the consultation with the doctor on the 22nd May 2024 the patient 
reported that she was taking sertraline 
on the day by the doctor.  A brief letter was sent to the GP on the same day requesting an 
increase in dose of Sertraline (t
that the patient was in fact prescribed and reporting use of sertraline 200 mg.  This is the 
maximum licensed dose.  This meant there was no role for recommending a further increase, 
and the appropriate course of action was to review the patient at her next planned 
appointment which would be on 1st July 2024 to consider alternative treatment options.  At 
this time there were no indications to suggest a need to bring the appointment forward. 

).  The GP responded on the 24th May 2024 advising 

 and this was documented in the clinical notes 

On reflection, the discrepancy between the dosage understood by the doctor, based on the 
patient’s account, and the dosage confirmed by the GP was not recorded in the clinical 
notes. In addition, the actions required following receipt of the GP’s response were not 
documented. 

Whilst this discrepancy was not causative of the sad outcome in this matter, reliance on the 
patient’s report was made in good faith as part of the therapeutic process. I can assure the 
Court that, moving forward, the importance of clearly recording and communicating any 
inconsistencies between a patient’s reported medication dosage and the dosage prescribed 
by the GP will be reinforced with the medical team, in order to ensure safe and effective 
prescribing and to minimise the risk of confusion. 

 
 
 
 
 
 
 
 
 
 
 
 Concern 3)  There were issues around communication and escalation within the Trust 
mental health team. A routine 6-month blood anti-psychotic to check clozapine levels assay 
was taken on 3 June and the results reported on 7 June were sent to the psychiatrist and 
showed markedly sub therapeutic blood levels of antipsychotic medication. This 
subtherapeutic level was not acted upon and was contrary to: 

a. Ms Ahmetaj insisting she was compliant with her medication 
b. Ms Ahmetaj did not have any noted risks that would cause interference with her 
medication. 
c. Ms Ahmetaj informed EPUT clinicians that: 

i. On 24 June she thought her medication Clozapine was not working 
ii. On 27 June she no longer wished to take her prescribed antipsychotic medication, and 
iii. Did not agree she had Schizophrenia, and 
iv. wanted to revert to a previous medication Quetiapine. 

These matters were not escalated to the psychiatrist and Ms Ahmetaj was informed to 
continue her clozapine and wait for her appointment on 1 July and there was no 
consideration of the risk of relapse of psychosis. 

Response:   

The plasma Clozapine assay undertaken on 3rd June 2024 and reported on 7th June 
demonstrated a markedly low levels of clozapine in the plasma.  The result were reviewed by 
the clinical team. It is important to emphasise that this did not reflect sub-therapeutic 
prescribing, as the patient’s Clozapine dose had remained unchanged since discharge. A 
previous Clozapine assay undertaken in 2023, at the same dosage, confirmed a therapeutic 
plasma level of 0.53.   

National and local guidelines emphasise that Clozapine plasma levels are an adjunct to 
clinical decision-making and should not be used in isolation to guide practice. Clinical 
assessment of the patient remains the primary determinant of treatment intervention. 

The most likely cause of unexpectedly low plasma levels is non-adherence.  Accordingly, the 
first step in clinical management should be to review the patient’s report of compliance. Other 
factors may also influence assay results, particularly the timing of blood sampling in relation 
to dosing, an important consideration for patients prescribed Clozapine twice daily. These 
aspects should be explored with the patient before any treatment changes or dose 
adjustments are recommended, which was put in place for this patient (see further below) 

In this case, the patient had been maintained on the same Clozapine dose for over one year, 
with previously documented therapeutic levels.  Between 7th June (when the assay result 
became available) and 27th June, the patient was reviewed on five occasions by the 
community mental health team. No evidence of rebound psychosis or acute relapse was 
identified during these reviews.  An appointment with the consultant psychiatrist was already 
scheduled for 1 July and there was no indication of a need to bring forward appointment 
based on the community contacts.   

As set out in evidence at this hearing, Ms Brahimi engaged well with the community team 
and was seen both at home and at clinic.  She presented well and very consistent and this 
was documented in her medical record.  We acknowledge that the documentation was 
lacking in explicitly linking the low clozapine levels and monitoring of mental state through 

 
 
 
 
 
 
 
 
 
  
 
 
 
 community contacts.  As stated above, in the event that a patient displays deterioration in 
mental health state the community staff would escalate this to the consultant. 

It is recognised that urgent escalation is generally indicated where Clozapine plasma levels 
are found to be elevated due to the risk of toxicity. In contrast, guidance for low levels 
suggests the following pathways: 

•
markedly from previous assays on a stable dose and no external factors are evident.

Consider repeating the assay if results are unexpected, particularly where they differ

•
presentation before initiating treatment changes.

Assess whether the laboratory finding is consistent with the patient’s clinical

On reflection, while the management of this case was consistent with current guidance, there 
are learning points regarding communication and escalation.  Specifically, inconsistencies 
between assay findings, patient-reported adherence, and clinical stability should have been 
explicitly documented and escalated to the consultant psychiatrist at an earlier stage. Doing 
so would have provided additional assurance around risk management and strengthened the 
therapeutic dialogue with the patient. This learning is being taken forward by the MDT. 

Concern 4) The mental health Trust record-keeping did not contain all relevant information 
relating  to the  care  and treatment there  were  omissions relating to  symptoms  and  potential 
signs of deterioration and compliance with medication. 

Response:  

The Trust recognises that quality record keeping is a challenge for NHS organisations and as 
such there is continuous focused improvement work undertaken across the Trust.  We were 
grateful for your acknowledgment of the improvements in clinical documentation in respect of 
cases coming before your Court.  

We offer our assurences to the Court and the family in respect of the robust monitoring 
methodologies for record keeping including an annual audit, regular local audits using the 
Trust Tendable system and record keeping reviews as part of 1:1 supervision with staff.  
Staff hold a professional responsibility for good practice in their record keeping and all staff 
are regularly reminded of this. 

Additionally we can confirm that discussions have been undertaken with service leads with 
regards to record keeping in respect of this particular case and highlighting importance of 
timely and detailed record keeping.  Service Managers were tasked to emphasise the 
importance of this service staff. 

The Trust has continued with a Record Keeping Safety Improvement Programme (SIP). This 
SIP program is focusing on improving patient safety in respect of documentation specifically. 
The approach will be to support continuous learning and improvement and regular review.  

To further support staff the Trust has developed a new Clinical record keeping guidance to 
help guide staff on what is a good clinical record.   

 Concern 5) Clozapine constipation was raised as a serious side effect such that there is  a 
Trust policy to manage this matter. This was not dealt with within the Trust for Ms Ahmetaj, 
and it took two weeks to raise this for the GP to manage. This did not cause or contribute to 
Ms Ahmetaj’s death however there is a concern for the long delay for other patients. 

Response:  

The importance of bowel habits is covered in the clozapine clinic protocol and in section 2 of 
the Formulary and Prescribing Guidelines. This includes a template letter (Appendix 3 of 
Section 2 ) for use when patients are initiated on clozapine to inform the patient’s GP 
practice that there are side effects, including constipation and interactions that they need to 
be alert for. The clozapine clinic protocol includes a proforma for monitoring side effects and 
specifically highlights the need to ask patients about bowel habits. 

Ms Brahimi was reviewed in the outpatient clinic on 22 May 2024, and a letter was sent to 
the GP on 7 June 2024 flagging concerns about constipation. Whilst the GP was of course 
able to obtain any further detail from the clinic as required, it is acknowledged that the letter 
did not provide sufficient clinical detail, such as current severity, frequency of bowel 
movements, or associated symptoms. The patient’s presentation at this time did not however 
indicate a deterioration or any other serious complication at this stage. The lack of sufficient 
detail within the letter, whilst regrettable, (and as acknowledged in the PFD report) did not 
contribute or directly cause the patient’s sad death.   

We can assure the court that the Trust provides staff with clear guidance in the Clozapine 
policy last issued in January 2025 on the assessment, monitoring, and documentation of 
Clozapine-related constipation. The updated policy from January 2025 has been 
disseminated widely across the medical teams, and a dedicated teaching session took place 
on 2nd of October 2025 to reinforce best practice in the monitoring and documentation of 
Clozapine side effects. 

I hope that I have provided some reassurances around the steps that we have taken to address 
the issues of concern contained within your report.  We know there is an acute need to embed 
and effect change, hence we will monitor the above provisions to ensure these are contributing 
to our overall aim of keeping patents safe and delivering therapeutic care. 

Please do let me know if you require any further information at this stage. 

We understand that a copy of this reply will be shared with the family.   

Yours sincerely, 

Chief Executive