Mark Turner

I am Emma Serrano, Area Coroner, for the coroner area of Staffordshire.

On the 25 th April 2025, I commenced an investigation into the death of Mr Turner.  The investigation concluded at the end of the inquest on 14 January 2026. The conclusion of the inquest was a narrative conclusion of “complication following necessary medical treatment” . The cause of death was: 1a Citalopram toxicity

i)    Mr   Turner   was   a   63-year-old   man,   who   suffered   from   paranoid schizophrenia.  Amongst other medications, he was prescribed citalopram. He was taking this in accordance with his prescription.  The prescription was issues appropriately.  On the 18 April 2025, he was found deceased at his home address. ii)   He was also prescribed clozapine, which needed be monitored weekly via a blood test and to have a serum text every 6 months. iii)  A postmortem revealed that he had passed away from citalopram toxicity.  It was agreed in evidence that this was a complication that could result from the use of citalopram, even when used in accordance with the prescriber’s instructions.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows.

1. 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.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.