PFD report

Jack Horace BURTON · Prevention of Future Deaths report

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Issued 3 Jun 2026•Worcestershire

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.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised3

  1. Lack of standardised guidance for recording answers about possible medication side effects
    Part of recurring concern: Unreliable clinician management of medication side effects
  2. Lack of guidance on the relevance of smoking reduction rather than smoking cessation
  3. Lack of standardised guidance for asking questions about possible medication side effects
    Part of recurring concern: Failure to identify clinically significant medication risksPart 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.

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.4

  1. Action

    Re-issue the Clozapine Treatment Guidelines and clinic guidance to the mental health clinical workforce.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
  2. Action

    Undertake follow-up to ensure newly appointed and existing staff are aware of and comply with both clozapine guidance documents.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 28 July 2026.
  3. Action

    Maintain current Clozapine Treatment Guidelines addressing smoking cessation and smoking reduction effects on clozapine levels.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Guidance on clozapine management during smoking reduction or cessation already exists, contrary to the concern that no guidance was available.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 standardised guidance for recording answers about possible medication side effects

Wider context from the report

“2. The evidence revealed that there is no guidance on any standardised practice available to practitioners relating to asking questions and recording answers given when discussing possible symptoms of side effects of the medication. Practitioners can therefore make no record if no information is provided, which does not indicate whether questions were asked. ”

Is this part of a recurring concern?

Yes — Unreliable clinician management of medication side effects.

Open source report

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 the relevance of smoking reduction rather than smoking cessation

Wider context from the report

“1. There were inconsistent accounts provided to me by two consultant psychiatrists, about the relevance of reduction in smoking, rather than cessation of smoking, attributable to there being no guidance available to doctors on this issue. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 standardised guidance for asking questions about possible medication side effects

Wider context from the report

“2. The evidence revealed that there is no guidance on any standardised practice available to practitioners relating to asking questions and recording answers given when discussing possible symptoms of side effects of the medication. Practitioners can therefore make no record if no information is provided, which does not indicate whether questions were asked. ”

Is this part of a recurring concern?

Yes — Failure to identify clinically significant medication risks; Unreliable clinician management of medication side effects.

Open source report

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

Re-issue the Clozapine Treatment Guidelines and clinic guidance to the mental health clinical workforce.

Verbatim wording from the response

“In further response to the concerns raised by the Coroner, the Trust has re-issued both documents to the mental health clinical workforce. Follow-up actions will be undertaken to ensure that both newly appointed and existing staff are aware of, and comply with, the guidelines.”

Source location

Response from Herefordshire and Worcestershire NHS Trust
Page 2 · response
Published 28 July 2026

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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

Undertake follow-up to ensure newly appointed and existing staff are aware of and comply with both clozapine guidance documents.

Verbatim wording from the response

“In further response to the concerns raised by the Coroner, the Trust has re-issued both documents to the mental health clinical workforce. Follow-up actions will be undertaken to ensure that both newly appointed and existing staff are aware of, and comply with, the guidelines.”

Source location

Response from Herefordshire and Worcestershire NHS Trust
Page 2 · response
Published 28 July 2026

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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

Maintain current Clozapine Treatment Guidelines addressing smoking cessation and smoking reduction effects on clozapine levels.

Verbatim wording from the response

“Herefordshire and Worcestershire Health and Care Trust have Clozapine Treatment Guidelines in date and available on the Trust Intranet site.”

Source location

Response from Herefordshire and Worcestershire NHS Trust
Page 1 · response
Published 28 July 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

Use the Clozapine Clinic standard operating procedure and GASS to monitor and record clozapine side effects in electronic patient records.

Verbatim wording from the response

“Herefordshire and Worcestershire Health and Care Trust have a standard operating procedure, Community Mental Health Team’s Clozapine Clinic Guidance and Promotion of Health & Wellbeing, this document is in date and available on the Trust intranet. Please find the document attached.”

Source location

Response from Herefordshire and Worcestershire NHS Trust
Page 2 · response
Published 28 July 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 on clozapine management during smoking reduction or cessation already exists, contrary to the concern that no guidance was available.

Verbatim wording from the response

“1. There were inconsistent accounts provided to me by two Consultant Psychiatrists, about the relevance in reduction in smoking, rather than cessation of smoking, attributable to there being no guidance available to doctors on this issue.”

Source location

Response from Herefordshire and Worcestershire NHS Trust
Page 1 · response
Published 28 July 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 Trust clozapine treatment guidelines address the effects of smoking reduction and cessation on clozapine levels.

Verbatim wording from the response

“Herefordshire and Worcestershire Health and Care Trust have Clozapine Treatment Guidelines in date and available on the Trust Intranet site.”

Source location

Response from Herefordshire and Worcestershire NHS Trust
Page 1 · response
Published 28 July 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 positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Existing standard operating procedures require side-effect monitoring using GASS, with results recorded in electronic health records and followed up clinically.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 standard operating procedures require side-effect monitoring using GASS, with results recorded in electronic health records and followed up clinically.

Verbatim wording from the response

“Herefordshire and Worcestershire Health and Care Trust have a standard operating procedure, Community Mental Health Team’s Clozapine Clinic Guidance and Promotion of Health & Wellbeing, this document is in date and available on the Trust intranet. Please find the document attached.”

Source location

Response from Herefordshire and Worcestershire NHS Trust
Page 2 · response
Published 28 July 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