Worcester man died of drug toxicity after quitting smoking

A 29-year-old man taking anti-psychotic medication died when the levels of the drug in his blood became toxic due to him giving up smoking.

Jack Burton from Worcester had been prescribed 525mg of clozapine for paranoid schizophrenia by his community psychiatrist, the correct dosage for when he was smoking.

Burton had been regularly advised that stopping smoking would increase his clozapine levels, an inquest into his death heard.

However, the 29-year-old died while on holiday in Scarborough on 7 October 2025, shortly after giving up smoking, with the results of a post-mortem and toxicology indicating that his death was due to clozapine toxicity.

His sister confirmed that Burton was a heavy smoker and was taking his 525mg of clozapine nightly as prescribed, but did not smoke while they had been on holiday.

The inquest heard that he stopped smoking tobacco on or before 4 October 2025, with coroner Deborah Lakin concluding that it was likely that this led to a fatal increase in the levels of clozapine in his blood.

She added that Burton, who was under primary and secondary healthcare services in Worcester, should have informed his psychiatrist if he had stopped or reduced his smoking, so he could reduce the amount of clozapine he was taking, as otherwise it could cause seizures.

In a prevention of future deaths report, Lakin said she had been provided inconsistent accounts by two consultant psychiatrists about the relevance of reducing the amount of smoking, attributable to there being no guidance available to doctors on the issue.

She said evidence revealed there was 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.

Lakin said she was concerned future deaths would occur unless action was taken.