Darragh Coffey represented the family of William Northcott before Devon, Plymouth and Torbay’s Coroner’s Court over five days of an inquest into the 39-year-old’s death. The Coroner found that William died from a toxic mix of his prescription drugs as well as a small amount of amphetamine. He was also found to have had an enlarged heart which was not picked up on by those prescribing his medication.

Recording mixed drug toxicity as the primary cause of William’s death, Assistant Coroner, Louise Wiltshire also identified that there were multiple gaps in the monitoring of William’s levels of the drug clozapine, which can have fatal consequences if appropriate physical health checks are not done. Whilst she did not find that these gaps were causative, they indicate significant gaps in this important monitoring regime for William’s medication.

The Coroner heard evidence that since William’s death some patients in Devon are now seen in specialist clozapine clinics, but 40% of those who are prescribed clozapine are still not under these specialist clinics. Using her powers to issue Prevent Future Death Reports, the Coroner expressed concern that this may mean that those patients do not get the same standard of care. She was also concerned about whether there are adequate arrangements for sharing information between GPs and the Trust. She has also asked the Trust to clarify how communication between the Trust (those who prescribe these drugs) and those who support patients in the community to ensure that information flows both ways.

Significantly the Coroner expressed a further national concern that patients are not receiving cardiac tests before being prescribed drugs like clozapine and will raise her concern with the MHRA and NHS England who will be required to respond.

Darragh was instructed on behalf of William’s family by Anna Moore of Leigh Day.

Press coverage of this inquest is available here and here.