Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0274, written 3 Jun 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Jun 2026 |
|---|---|
| Reference | 2026-0274 |
| Deceased | Jack Burton |
| Coroner | Deborah Lakin |
| Coroner area | Worcestershire |
| Source | judiciary.uk record |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REPORT TO PREVENT FUTURE DEATHS REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). 1. 2. 3. CORONER I am Deborah LAKIN, HM Assistant Coroner, for the coroner area of Worcestershire. DATE OF REPORT 03 June 2026 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. 4. THIS REPORT IS BEING SENT TO 1. Herefordshire & Worcestershire Health & Care NHS Trust You are under a duty to respond to this report within 56 days of the date of this report, namely by July 26, 2026. I, the coroner, may extend the period if an appropriate application is made. 5. YOUR RESPONSE 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. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports - Courts and Tribunals Judiciary. 6. SUMMARY OF CORONER’S CONCERN ACTION SHOULD BE TAKEN In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action. 8. INVESTIGATION AND INQUEST On 04 February 2026 I commenced an investigation and opened an inquest into the death of Jack Horace BURTON aged 29. The investigation concluded at the end of the inquest on 14 May 2026. The conclusion of the inquest was that: Narrative Conclusion - Jack Horace Burton died on 7 October 2025 at 76 Moorland Road, Scarborough, North Yorkshire of Clozapine toxicity. Mr Burton had been prescribed Clozapine for schizophrenia and he was a smoker, who had been regularly advised that any cessation of smoking would increase Clozapine levels. Mr Burton stopped smoking tobacco on or before 4 October 2025. On the evidence it is likely that this led to a fatal increase in Clozapine blood levels. 9. CIRCUMSTANCES OF DEATH The deceased resided in Worcester and was under primary and secondary healthcare services in that area. He had a diagnosis of paranoid schizophrenia and was prescribed Clozapine by his community psychiatrist. He died while on holiday in North Yorkshire and the results of the post-mortem and toxicology indicate his death was due to Clozapine toxicity. His sister confirmed that Jack was a heavy smoker and was taking 525mg Clozapine nightly as prescribed, which is the correct dose when he is smoking, however whilst they have been on holiday he did not smoke . If he had stopped or reduced his smoking he should have informed his psychiatrist to reduce the amount of Clozapine he was taking , as this could cause seizures. 10. CORONER’S CONCERNS During the course of the inquest I heard evidence giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. There were inconsistent accounts provided to me by two consultant psychiatrists, about the relevance of reduction in smoking, rather than cessation of smoking, attributable to there being no guidance available to doctors on this issue. 2. The evidence revealed that there is no guidance on any standardised practice available to practitioners relating to asking questions and recording answers given when discussing possible symptoms of side effects of the medication. Practitioners can therefore make no record if no information is provided, which does not indicate whether questions were asked. 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles] (cid:127) I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE Deborah LAKIN HM Assistant Coroner for Worcestershire
1 response 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.
Chief Executives Office 2 Kings Court Charles Hastings Way Worcester WR5 1JR 25 June 2026 HM Assistant Coroner Martins Way Stourport-on-Severn Worcestershire DY13 8UN Dear Deborah Lakin, Re: Regulation 28 response – Jack Horace Burton Thank you for forwarding on your Regulation 28 report, the concerns that you raised have been noted and I respond to your matters of concern as below:- 1. There were inconsistent accounts provided to me by two Consultant Psychiatrists, about the relevance in reduction in smoking, rather than cessation of smoking, attributable to there being no guidance available to doctors on this issue. Herefordshire and Worcestershire Health and Care Trust have Clozapine Treatment Guidelines in date and available on the Trust Intranet site. This guidance was authored by Pharmacist, Mental Health, Herefordshire. , Chief Pharmacist and Juliet Shepherd, Lead The guidance was ratified in February 2022 and has had regular review with a current review date of February 2029. Please find the document attached. The guidelines make clear reference to the impact of both smoking cessation and reduction. “Smoking Cessation. The aromatic hydrocarbons in tobacco smoke induce the enzyme CYP1A2 – which reduces plasma clozapine levels. Therefore, a person who smokes tobacco regularly may need a higher dose of clozapine than someone who does not smoke tobacco. If a patient reduces their level of smoking tobacco the level of clozapine available in their body will rise. This change can be dramatic and potentially result in overdose or toxic plasma levels of clozapine.” The Trust would also like to point out there is clear national guidance available on this issue in the link below: Managing specific interactions with smoking – NHS SPS - Specialist Pharmacy Service – The first stop for professional medicines advice 2. The evidence revealed that there is no guidance on any standardised practice available to practitioners relating to asking questions and recording answers given when discussing possible symptoms of side effects of the medication. Practitioners can therefore make no record if no information is provided, which does not indicate whether questions were asked. Herefordshire and Worcestershire Health and Care Trust have a standard operating procedure, Community Mental Health Team’s Clozapine Clinic Guidance and Promotion of Health & Wellbeing, this document is in date and available on the Trust intranet. Please find the document attached. As documented within the standard operating procedure it is standard practice for Trust practitioners to monitor for any side effects of Clozapine, and this is completed by using the Glasgow Antipsychotic Side-effect Scale (GASS). The outputs from this are then recorded with the patient electronic health record and followed up as clinically indicated. In further response to the concerns raised by the Coroner, the Trust has re-issued both documents to the mental health clinical workforce. Follow-up actions will be undertaken to ensure that both newly appointed and existing staff are aware of, and comply with, the guidelines. Yours sincerely Chief Executive Enc.
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