Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Mark Anthony Turner who died on 18th April 2025.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 14th January 2026 concerning the death of Mark Anthony Turner, who was found deceased on 18th April 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Turner’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Mark’s care have been listened to and reflected upon.

Your Report raises a concern that there is no guidance locally or nationally as to what steps should be taken when a high serum level is returned in patients taking clozapine who are being monitored. In the majority of NHS trusts clozapine treatment will be undertaken though a dedicated clozapine clinic where the overall safe prescribing and associated monitoring will be undertaken. Information from a number of different sources is currently available to support prescriber’s decisions in relation to Clozapine (or norclozapine) plasma levels, including in cases of high serum levels. These include:
• Information from the manufacturers about plasma level monitoring: o CPMS Factsheet 20 - TDM Update v1 o FS_CPN metabolism_plasma level_jun2019.pdf
• The Maudsley prescribing guidelines (available to all NHS users through their NHS Athens account)
• Specialist Pharmacy Service (SPS), which is commissioned by NHS England to provide advice and guidance on medicines also offer guidance on clozapine monitoring (Clinical considerations for patients prescribed clozapine – NHS SPS - Specialist Pharmacy Service – The first stop for professional medicines advice ) National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

england.coronersr28@nhs.net 26 March 2026

Most trusts should also have in place their own local guideline(s) on the management of clozapine plasma levels. Some examples from trusts in England include:
• Microsoft Word - Clozapine Plasma Level monitoring Final 6 with logos.docx
• Clozapine-role-of-therapeutic-drug-monitoring.pdf
• Clozapine TDM poster -September 2025.pdf In Scotland Therapeutic Drug Monitoring (Clozapine) | Right Decisions is another useful resource that could be adopted for use by local Clozapine services. In summary, the interpretation of clozapine plasma levels should be individualised at trust level, based on the general guidance contained in all the above information. In response to this case, NHS England has written to all Mental Health Chief Pharmacists in England to ask them to work with their local clozapine clinics to review the information and support materials that they use. This is to help ensure the safe and appropriate use of plasma level monitoring within their Trusts, and ensure these are up to date and embedded locally.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Mark, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Ms Serrano Regulation 28 Report following the Inquest touching upon the death of Mr Mark Turner I am writing to in response to the Regulation 28 Report dated 14 January 2026, following the Inquest relating to Mr Turner’s death. On behalf of MPFT I would first like to offer my sincere condolences to Mr Turner’s friends and family for their tragic loss. During the inquest into Mr Turner’s death, evidence confirmed that he had been prescribed clozapine as part of the management of his mental health condition. Patients who are prescribed clozapine should undergo monthly blood test monitoring in order to check for any signs of toxicity and in addition, should undergo 6 monthly blood serum (plasma) testing to check the levels of clozapine in their system. Your concern as documented in the Prevention of Future Deaths report is follows: That when a high serum level is returned in patients being monitored as they are taking clozapine, there is no guidance, locally or nationally as to what steps should be taken. Midlands Partnership University Hospitals Trust does have a Standard Operating Procedure (SOP) in place relating to clozapine. We are sorry that the evidence heard at inquest contradicted the actual position. The SOP sets out the criteria which need to be adhered to when using clozapine to ensure safe and effective practice and includes information and support to clinicians in relation to the prescribing, monitoring, administration and supply of clozapine. The current version of the SOP has been in place since July 2024 and was in place at the time of Mr Turner’s death in April
2025. A copy of the SOP is attached for ease. The SOP refers to clozapine serum level, clozapine plasma level and trough plasma clozapine concentration, these phrases can be used interchangeably, they are all the same thing and are what is monitored at the 6 monthly blood tests. Appendix 1 of the SOP provides a guide for clinicians to follow when assessing clozapine serum levels depending on the level of clozapine serum found (see pages 26-28 of the SOP). For

80163615v1 instance, the SOP states that if the serum level is less than 0.35 and the patient is displaying “good” clinical response to taking clozapine, then the clinician should “consider repeating levels every 6 months unless patient develops troublesome side effects or deteriorates”. The SOP contains what is considered to be guidance to support clinical decision making. There are a number of patient variability factors that would need to be taken into account when clinical staff are making decisions, for example, the clinician would need to consider if the patient is displaying any signs of toxicity and if there would be any potential impact on the patient’s mental health if clozapine were to be reduced or stopped, ahead of making a decision and for that reason guidance is not more prescriptive. The SOP is readily available for all staff to access on the Trust’s intranet site. Since the inquest the SOP has been recirculated to all prescribers in the Integrated Mental Health Team in Burntwood and Lichfield. The application of this SOP has also been discussed with the team. I hope that this goes some way to allay concerns in relation to this matter, but should you require any further information please do not hesitate to contact me. Should you have any further questions please do not hesitate to contact