PFD report

Katharine Eva Stamp · Prevention of Future Deaths report

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Issued 18 Dec 2019•West Sussex

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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

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Concerns raised2

  1. Under-appreciation of clozapine side effects relating to smoking and pneumonia
    Part of recurring concern: Failure to identify clinically significant medication risksPart of recurring concern: Unreliable clinician management of medication side effectsPart of recurring concern: Unreliable safety monitoring and guidance for clozapine treatment
  2. Insufficient BNF clarity about clozapine side effects
    Part of recurring concern: Incomplete medication safety guidance for prescribersPart of recurring concern: Unreliable clinician management of medication side effects
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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

Under-appreciation of clozapine side effects relating to smoking and pneumonia

Wider context from the report

“The side effects of clozapine, with specific reference to smoking and pneumonia, are under-appreciated Professor ████████ gave expert evidence to the Court These side effects may be rare, but they are still important The BNF does not provide sufficient clarity to prescribers about these side-effects ”

Is this part of a recurring concern?

Yes — Failure to identify clinically significant medication risks; Unreliable clinician management of medication side effects; Unreliable safety monitoring and guidance for clozapine treatment.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient BNF clarity about clozapine side effects

Wider context from the report

“The side effects of clozapine, with specific reference to smoking and pneumonia, are under-appreciated Professor ████████ gave expert evidence to the Court These side effects may be rare, but they are still important The BNF does not provide sufficient clarity to prescribers about these side-effects ”

Is this part of a recurring concern?

Yes — Incomplete medication safety guidance for prescribers; Unreliable clinician management of medication side effects.

Open source report
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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