PFD report

Mr Turner · Prevention of Future Deaths report

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Issued 14 Jan 2026•Staffordshire and Stoke-on-Trent

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of guidance on steps to take when high serum clozapine levels are returned
    Part of recurring concern: Unreliable medication-specific blood-level monitoringPart of recurring concern: Unreliable safety monitoring and guidance for clozapine treatment
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Write to all Mental Health Chief Pharmacists requesting local clozapine clinics review and update plasma-level monitoring information and support materials.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
  2. Action

    Maintain a clozapine standard operating procedure covering prescribing, monitoring, administration, supply and assessment of serum levels.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
  3. Action

    Recirculate the clozapine standard operating procedure to all Integrated Mental Health Team prescribers in Burntwood and Lichfield.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Interpretation of clozapine plasma levels is assigned to individual trusts, based on general guidance and local clinical circumstances.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of guidance on steps to take when high serum clozapine levels are returned

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Unreliable medication-specific blood-level monitoring; Unreliable safety monitoring and guidance for clozapine treatment.

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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

Write to all Mental Health Chief Pharmacists requesting local clozapine clinics review and update plasma-level monitoring information and support materials.

Verbatim wording from the response

“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.”

Source location

2026-0065 - Response from NHS England
Page 2 · response
Published 10 February 2026

Open published response

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

Maintain a clozapine standard operating procedure covering prescribing, monitoring, administration, supply and assessment of serum levels.

Verbatim wording from the response

“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.”

Source location

2026-0065 - Response from Midlands Partnership University NHS Foundation Trust
Page 1 · response
Published 10 February 2026

Open published response

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

Recirculate the clozapine standard operating procedure to all Integrated Mental Health Team prescribers in Burntwood and Lichfield.

Verbatim wording from the response

“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.”

Source location

2026-0065 - Response from Midlands Partnership University NHS Foundation Trust
Page 2 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Interpretation of clozapine plasma levels is assigned to individual trusts, based on general guidance and local clinical circumstances.

Verbatim wording from the response

“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.”

Source location

2026-0065 - Response from NHS England
Page 2 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing national and local guidance is considered sufficient to support decisions on high clozapine plasma levels.

Verbatim wording from the response

“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.”

Source location

2026-0065 - Response from NHS England
Page 1 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Guidance cannot be more prescriptive because individual toxicity, clinical response and mental-health risks require clinician-specific decisions.

Verbatim wording from the response

“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.”

Source location

2026-0065 - Response from Midlands Partnership University NHS Foundation Trust
Page 2 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

A Trust SOP already provides local guidance on assessing high clozapine serum levels.

Verbatim wording from the response

“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.”

Source location

2026-0065 - Response from Midlands Partnership University NHS Foundation Trust
Page 1 · response
Published 10 February 2026

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
  2. 2

    Discuss application of the clozapine standard operating procedure with the Integrated Mental Health Team in Burntwood and Lichfield.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.

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

Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

Verbatim wording from the response

“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.”

Source location

2026-0065 - Response from NHS England
Page 2 · response
Published 10 February 2026

Open published response

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

Discuss application of the clozapine standard operating procedure with the Integrated Mental Health Team in Burntwood and Lichfield.

Verbatim wording from the response

“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.”

Source location

2026-0065 - Response from Midlands Partnership University NHS Foundation Trust
Page 2 · response
Published 10 February 2026

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026