Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0065, written 14 Jan 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Jan 2026 |
|---|---|
| Reference | 2026-0065 |
| Deceased | Mark Turner |
| Coroner | Emma Serrano |
| Coroner area | Staffordshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Midlands Partnership Foundation Trust; and 2. NHS England. 1 CORONER I am Emma Serrano, Area Coroner, for the coroner area of Staffordshire. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On the 25th April 2025, I commenced an investigation into the death of Mr Turner. The investigation concluded at the end of the inquest on 14 January 2026. The conclusion of the inquest was a narrative conclusion of “complication following necessary medical treatment”. The cause of death was: 1a Citalopram toxicity CIRCUMSTANCES OF THE DEATH 4 i) Mr Turner was a 63-year-old man, who suffered from paranoid schizophrenia. Amongst other medications, he was prescribed citalopram. He was taking this in accordance with his prescription. The prescription was issues appropriately. On the 18 April 2025, he was found deceased at his home address. ii) He was also prescribed clozapine, which needed be monitored weekly via a blood test and to have a serum text every 6 months. iii) A postmortem revealed that he had passed away from citalopram toxicity. It was agreed in evidence that this was a complication that could result from the use of citalopram, even when used in accordance with the prescriber’s instructions. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 1 [IL1: PROTECT] The MATTERS OF CONCERN are as follows. – 1. That when a high serum level is returned in patients being monitored as they are taking clozapine, there is no guidance, locally or nationally as to what steps should be taken. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 3 April 2026. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. Family of the deceased. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 14 January 2026 Miss Emma Serrano Area Coroner Staffordshire 2 [IL1: PROTECT]
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Trust Headquarters
St George's Hospital
Corporation Street
Stafford ST16 3SR
www.mpft.nhs.uk
2 April 2026
Miss Emma Serrano
Area Coroner for Staffordshire
By email
Dear Ms Serrano
Regulation 28 Report following the Inquest touching upon the death of Mr Mark Turner
I am writing to in response to the Regulation 28 Report dated 14 January 2026, following the
Inquest relating to Mr Turner’s death.
On behalf of MPFT I would first like to offer my sincere condolences to Mr Turner’s friends and
family for their tragic loss.
During the inquest into Mr Turner’s death, evidence confirmed that he had been prescribed
clozapine as part of the management of his mental health condition. Patients who are prescribed
clozapine should undergo monthly blood test monitoring in order to check for any signs of toxicity
and in addition, should undergo 6 monthly blood serum (plasma) testing to check the levels of
clozapine in their system.
Your concern as documented in the Prevention of Future Deaths report is follows:
That when a high serum level is returned in patients being monitored as they are taking
clozapine, there is no guidance, locally or nationally as to what steps should be taken.
Midlands Partnership University Hospitals Trust does have a Standard Operating Procedure (SOP)
in place relating to clozapine. We are sorry that the evidence heard at inquest contradicted the
actual position. The SOP sets out the criteria which need to be adhered to when using clozapine
to ensure safe and effective practice and includes information and support to clinicians in relation
to the prescribing, monitoring, administration and supply of clozapine. The current version of the
SOP has been in place since July 2024 and was in place at the time of Mr Turner’s death in April
2025. A copy of the SOP is attached for ease.
The SOP refers to clozapine serum level, clozapine plasma level and trough plasma clozapine
concentration, these phrases can be used interchangeably, they are all the same thing and are
what is monitored at the 6 monthly blood tests.
Appendix 1 of the SOP provides a guide for clinicians to follow when assessing clozapine serum
levels depending on the level of clozapine serum found (see pages 26-28 of the SOP). For
instance, the SOP states that if the serum level is less than 0.35 and the patient is displaying
“good” clinical response to taking clozapine, then the clinician should “consider repeating levels
every 6 months unless patient develops troublesome side effects or deteriorates”.
The SOP contains what is considered to be guidance to support clinical decision making. There
are a number of patient variability factors that would need to be taken into account when clinical
staff are making decisions, for example, the clinician would need to consider if the patient is
displaying any signs of toxicity and if there would be any potential impact on the patient’s mental
health if clozapine were to be reduced or stopped, ahead of making a decision and for that reason
guidance is not more prescriptive.
The SOP is readily available for all staff to access on the Trust’s intranet site. Since the inquest
the SOP has been recirculated to all prescribers in the Integrated Mental Health Team in
Burntwood and Lichfield. The application of this SOP has also been discussed with the team.
I hope that this goes some way to allay concerns in relation to this matter, but should you require
any further information please do not hesitate to contact me.
Should
you have any
further questions please do not hesitate
to
contact
Yours sincerely,
Chief Executive
Midlands Partnership NHS University NHS Foundation Trust
80163615v1
Emma Serrano
Area Coroner for Staffordshire
Stoke on Trent and
North Staffordshire Coroners Service
Stoke Town Hall
Kingsway
Stoke-on-Trent
ST4 1HH
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
england.coronersr28@nhs.net
26 March 2026
By Email: staffordshireandstokecoroners@stoke.gov.uk
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Mark Anthony Turner
who died on 18th April 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 14th
January 2026 concerning the death of Mark Anthony Turner, who was found deceased
on 18th April 2025. In advance of responding to the specific concerns raised in your
Report, I would like to express my deep condolences to Mr Turner’s family and loved
ones. NHS England is keen to assure the family and yourself that the concerns raised
about Mark’s care have been listened to and reflected upon.
Your Report raises a concern that there is no guidance locally or nationally as to what
steps should be taken when a high serum level is returned in patients taking clozapine
who are being monitored.
In the majority of NHS trusts clozapine treatment will be undertaken though a
dedicated clozapine clinic where the overall safe prescribing and associated
monitoring will be undertaken.
Information from a number of different sources is currently available to support
prescriber’s decisions in relation to Clozapine (or norclozapine) plasma levels,
including in cases of high serum levels. These include:
•
Information from the manufacturers about plasma level monitoring:
o CPMS Factsheet 20 - TDM Update v1
o FS_CPN metabolism_plasma level_jun2019.pdf
• The Maudsley prescribing guidelines (available to all NHS users through their
NHS Athens account)
• Specialist Pharmacy Service (SPS), which is commissioned by NHS England
to provide advice and guidance on medicines also offer guidance on clozapine
monitoring (Clinical considerations for patients prescribed clozapine – NHS
SPS - Specialist Pharmacy Service – The first stop for professional medicines
advice )
Most trusts should also have in place their own local guideline(s) on the management
of clozapine plasma levels. Some examples from trusts in England include:
• Microsoft Word - Clozapine Plasma Level monitoring Final 6 with logos.docx
• Clozapine-role-of-therapeutic-drug-monitoring.pdf
• Clozapine TDM poster -September 2025.pdf
In Scotland Therapeutic Drug Monitoring (Clozapine) | Right Decisions is another
useful resource that could be adopted for use by local Clozapine services.
In summary, the interpretation of clozapine plasma levels should be individualised at
trust level, based on the general guidance contained in all the above information.
In response to this case, NHS England has written to all Mental Health Chief
Pharmacists in England to ask them to work with their local clozapine clinics to review
the information and support materials that they use. This is to help ensure the safe
and appropriate use of plasma level monitoring within their Trusts, and ensure these
are up to date and embedded locally.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of Mark,
are shared across the NHS at both a national and regional level and helps us to pay
close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England
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