The father of the Deceased indicated that his son would drink significant amounts of caffeinated drinks and had also cut down on his smoking and that he felt this may have had a bearing on the levels of clozapine in his system and also that the flu like symptoms which his son had prior to his death may have been the result of clozapine toxicity He stated that although his son's clozapine levels were being regularly monitored, at no point was he ever made aware of the possible interaction between caffeine or the cessation/reduction of smoking in relation to clozapine levels, nor was he made aware of the possible warning signs of toxicity.

It was therefore felt that there should be greater emphasis placed on the sharing of this knowledge with users and with staff within the Community Mental Health Team It was also felt that due to memory issues, patients should be regularly reminded of this information.