12 Aug 2025 Resmije Ahmetaj · Prevention of Future Deaths report Essex
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Concerns raised 8 Incomplete mental health care records View source Failure to escalate and act on markedly subtherapeutic clozapine levels View source Failure to consider the risk of psychosis relapse View source Failure to verify antidepressant prescription doses View source Failure of the mental health team to undertake mental state examinations View source Lack of fall mitigation on the penultimate car park floor with a pedestrian link walkway View source Delays in managing clozapine constipation View source Delays in communication with the GP about antidepressant prescribing View source See 5 more concerns
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Resmije Ahmetaj · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Resmije Ahmetaj, also known as Merita Brahimi, died on 30 June 2024 from a traumatic head injury after falling from a height at a multi-storey car park while suffering an exacerbation of psychosis. The report identifies concerns about subtherapeutic antipsychotic medication levels not being acted on, communication and escalation within the mental health team, incomplete record-keeping, medication prescribing confusion, and safety mitigation on the car park’s penultimate floor.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to BTCM Limited; that does not assign responsibility.
PFD Monitor interpretation Incomplete mental health care records
Wider context from the report “(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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to BTCM Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and act on markedly subtherapeutic clozapine levels
Wider context from the report “(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 subtherapeutic 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to BTCM Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the risk of psychosis relapse
Wider context from the report “(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 subtherapeutic 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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to BTCM Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to verify antidepressant prescription doses
Wider context from the report “(2) There was confusion about the mental health Trust prescribing dose for Ms Ahmetaj antidepressant medication and an overreliance on discussions with her rather than checking the prescription dose and communication with the GP was delayed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to BTCM Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the mental health team to undertake mental state examinations
Wider context from the report “(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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to BTCM Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of fall mitigation on the penultimate car park floor with a pedestrian link walkway
Wider context from the report “(6) The car park has a link walkway to residential housing on the penultimate floor from where Resmije Ahmetaj fell. The top floor has mitigation that would prevent a person from jumping/falling but the penultimate floor that has a pedestrian link walkway does not . There is likely to be more pedestrian footfall on the penultimate floor as a consequence and any fall from this height would inevitably be fatal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to BTCM Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in managing clozapine constipation
Wider context from the report “(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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to BTCM Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in communication with the GP about antidepressant prescribing
Wider context from the report “(2) There was confusion about the mental health Trust prescribing dose for Ms Ahmetaj antidepressant medication and an overreliance on discussions with her rather than checking the prescription dose and communication with the GP was delayed .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain contractor quotes for proposed mesh stairway covers and extended railings at the car park pedestrian link walkway.
Verbatim wording from the response “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.” Source location Response from Basildon Car Park Management
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations