Michael Roy Mahon · Prevention of Future Deaths report

On 15th September 2016 I commenced an investigation into the death of Michael Roy Mahon. The investigation concluded on the 16th February 2017 and the conclusion was one of Narrative: Died as a result of dilated cardiomyopathy, a known complication of obesity and clozapine therapy.
The medical cause of death was
1a Dilated cardiomyopathy
b Obesity and clozapine therapy
c
II Alcohol use

Michael Roy Mahon was schizophrenic. He was prescribed clozapine for this. He became obese over a period of time. His overall health deteriorated and he attended the hospital on a number of occasions. On the 13th September 2016 he was at his home address ████████. He was seen by his brother at about 8am. Later that morning he was found dead on the sofa by his father.

In the course of the inquest I heard evidence that both annual and monthly tests should be undertaken where clozapine has been prescribed. The annual test was required to identify symptoms and potential side effects that would not necessarily be picked up on monthly tests. Michael Mahon had not had his annual test. This should have taken place in March 2016.It was accepted that there was no system to identify that the test had been missed and it was not noticed at any of his monthly checks.