A 29-year-old man taking anti-psychotic medication died when the levels of the drug in his blood became toxic after he stopped smoking. Jack Burton, from Worcester, had been prescribed 525mg of clozapine for paranoid schizophrenia, a dosage correct for when he was smoking.
Mr Burton had been regularly advised that stopping smoking would increase his clozapine levels, an inquest heard. He died on 7 October 2025 while on holiday in Scarborough, shortly after giving up smoking. A post-mortem and toxicology report indicated his death was due to clozapine toxicity.
Coroner Deborah Lakin concluded it was likely that stopping smoking on or before 4 October 2025 led to a fatal increase in the clozapine levels in his blood. She stated that Mr Burton should have informed his psychiatrist if he had stopped or reduced smoking so his medication could be adjusted, as otherwise it could cause seizures.
In a prevention of future deaths report, Ms Lakin noted inconsistent accounts from two consultant psychiatrists regarding the relevance of reducing smoking. She attributed this to a lack of available guidance for doctors on the issue. Ms Lakin expressed concern that future deaths could occur without action.