
Inquest finds 39-year-old William Northcott from Torquay died after his prescription drugs, along with amphetamine caused him to suffer a cardiac arrythmia
An inquest has found that 39-year-old William Northcott from Torquay died from a toxic mix of his prescription drugs as well as a small amount of amphetamine. He also had an enlarged heart which was not picked up on by those prescribing his medication.
Posted on 17 January 2025
The inquest heard how there was insufficient monitoring of his potentially lethal anti-psychotic medication clozapine by medics at Devon Partnership NHS Trust.
Recording mixed drug toxicity as the primary cause of death, Assistant Coroner for Devon, Plymouth and Torbay, Louise Wiltshire also identified 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.
William, known by his family as “Wim”, had a history of poor mental health and was diagnosed with autism, OCD and schizophrenia in around 2012. He died on 13 July 2021 at Georgian House care home in Torquay where he was receiving one-to-one support. He had been prescribed with anti-psychotic drug clozapine since 2012 as well as other anti-psychotic medication and had been under the care of Devon Partnership NHS Trust since that time.
The inquest at Devon County Hall in Exeter heard evidence over five days from Monday 13 to Friday 17 January, including details of the prescribing and monitoring of Wim’s medication. These included:
- William’s GP, the Pembroke Practice, withdrawing from a monitoring service for clozapine because it felt the service offered by Devon Partnership Trust was unsafe.
- Important health information held by GPs (such as an individual’s smoking status) was not always passed to those responsible for prescribing clozapine.
- The psychiatrist responsible for William’s prescription of clozapine only assessing him on one occasion, over the phone, since taking over his care. The coroner found that this was a missed opportunity to question William about any side effects he was suffering.
- The hospital pharmacist acknowledging that there were gaps in some of the physical health monitoring of William.
- A lack of communication between GPs, the core mental health team and WIlliam’s care home about important issues such as WIlliam’s smoking status and his levels of alcohol.
Evidence was also heard from the manufacturer of clozapine, Viatris, which was named as an Interested Person to the inquest by the coroner.
The Coroner found there were various missed opportunities in WIlliam’s physical health monitoring, including that a further blood test should have been done between October 2020 and August 2021 to check the levels of clozapine in his blood and that after a slightly elevated blood result in June 2021 (the month before he died), contact should have been made to those caring for him to check whether he was showing any “red flag” side effects. Although the Coroner could not say that these gaps contributed to William’s death, it does point to significant gaps in this important monitoring regime.
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 those 40% of patients not seen in specialist clinic may mean they do not get the same standard of care. She was also concerned 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.
William’s sister, Kate Spall, who also gave evidence at the inquest, has been working with the Royal College of Psychiatrists to create and implement “Wim’s Protocol”, a resource for clinicians to ensure safer monitoring of clozapine, to embed physical health in patient care and monitoring and to tackle to stigma of serious mental illness. “Wim’s Protocol” will be launched in 2025.
Kate Spall is represented by solicitor Anna Moore of law firm Leigh Day and Darragh Coffey of 1 Crown Office Row.
Speaking after the inquest, Kate Spall said:
“Wim was a one off, irreplaceable, treasure of a young man. The loss of Wim is incalculable. We are grateful to the coroner for finding failure in monitoring the side effects of his anti-psychotic Clozapine as a factor in his death. It is only in highlighting and fearlessly investigating these deaths that we can prevent others from dying. People with serious mental illness are arguably the most vulnerable in our society - if we fail them - we fail as a society. We want Wim’s legacy to save the lives of his peers.
“Our larger-than-life boy deserves a large legacy. That’s why for the past year, I have been working with Dr Lade Smith, the President of the Royal College of Psychiatrists to create and implement “Wim’s Protocol”. This will be a valuable resource for clinicians to ensure safer monitoring of clozapine, embed physical health in patient care and monitoring and finally, to tackle to stigma of serious mental illness. “Wim’s Protocol” will be launched in 2025, and I hope it will help avoid a repeat of the appalling tragedy our family has had to endure.”
The family’s solicitor, Leigh Day partner Anna Moore said:
“Whilst nothing can ever compensate Kate and her family for the loss of their much-loved brother and son, my client is pleased that the coroner has found there are lessons to be learned from the gaps in the monitoring of his medication shown in William’s case. Throughout this inquest, we have heard evidence of how medical staff at Devon Partnership Trust failed to adequately monitor the administration of the potentially lethal anti-psychotic drug clozapine to Wim. Kate would like to see that this trust and trusts around the country make urgent changes to their systems and protocols regarding this and other similar medications. She is also campaigning for greater awareness of the risks of clozapine and to improve the care of people with serious mental illness with “Wim’s Protocol”. I wish her well with this important initiative which she hopes will lead to improved safety for all those prescribed clozapine in future.”

Missed opportunities to change the outcome for Hackney artist Sophie O’Neill when schizophrenia drug clozapine caused fatal heart condition
Thirty-seven-year-old London artist Sophie O’Neill died of a rare heart condition myocarditis and liver failure caused by the anti-psychotic drug clozapine, an inquest was told.