The young man developed psychotic symptoms in 2014 at age 18 and came under mental health services. He was trialled on multiple different antipsychotic medications but none alleviated his symptoms. He also began heavily using drugs and alcohol to self-medicate and, over time, stopped working and became isolated, before taking his own life in 2019 at the age of 23.
At the inquest, the independent psychiatric expert criticised the failure to trial him on clozapine, as recommended by the NICE guidelines, and commented that his treatment plan did not go far enough and that this would have reduced the risk of suicide.
The Coroner recorded a short form of suicide but noted in Box 3 that his treatment “did not include the use of Clozapine antipsychotic medication which was available at the time and which could have made a difference to the outcome had it been prescribed.”