Sean Benjamin Crawford Inquest
Sean Benjamin Crawford, 41, was found dead in his home in Darlington on the 18th of December 2020 as a result of the combined toxic effect of alcohol and clozapine acting to suppress his central nervous system.
On the 25th of January 2024, a five-day inquest into the death of Sean Benjamin Crawford commenced, Alistar Smith and Lois Hepworth of Watson Woodhouse Solicitors was instructed by Sean’s family to assist with the process.
Sean’s journey with mental health services began in 1997 when he was diagnosed with Paranoid Schizophrenia following admission to a psychiatric hospital. He was prescribed Clozapine for the long term.
In 2005, Sean moved to Darlington and was referred to the Community Mental Health Team (CMHT). At this point, his mental health was considered stable and he was prescribed 350 mg of Clozapine. Throughout the years leading to his passing, Sean remained under the care of CMHT, where he was prescribed Clozapine daily. The Psychosis team reviewed his Clozapine dosage each month. Over the next couple of years, Sean’s Clozapine dosage was reduced and increased to align with his mental health.
On the 9th of December 2020, Allan, Sean’s brother, had a telephone discussion with the Nursing Associate Worker. Allan expressed his concerns about Sean’s mental health declining and an increase in alcohol consumption and difficulties with sleeping as well as expressing concerns regarding the smell of Sean’s urine. Following the phone call, a home visit was scheduled for the 11th of December 2020 but was later rearranged to the 14th of December. During the planned visit, they discussed Sean’s physical health and Allan again reported that there was a strong smell from Sean’s urine. It was agreed that a urinalysis would be carried out at the Clozapine Clinic.
On the 17th of December 2020, a scheduled home visit for Sean at Allan’s residence was arranged, but Sean failed to show up. Concerned about his well-being, Allan attempted to reach Sean via phone and even went to Sean’s house. Unfortunately, there was no response upon Allan’s arrival. However, he managed to contact Sean over the phone.
Unfortunately, the next evening Allan visited Sean’s home and could not get a response. After Police Officers gained entry, they found Sean dead. The inquest found Sean’s death was due to the combination of alcohol and clozapine, which both suppress the system. Neither Sean, his brother, Allan, or his sister-in-law, Nichola, were warned that having alcohol could have fatal consequences.
Allan had repeatedly been advised by Darlington Community Mental Health Team staff that Sean should not stop consuming alcohol altogether as it could have an adverse effect on his mental health.
The coroner found that the management of care plans and the recording of data on plasma levels and other health data by TEWV was dangerously inadequate.
In a recent analysis by The Times newspaper found an average of more than 400 clozapine linked deaths per year have been reported to the Medicines and Health Care Products Regulatory Agency (MHRA), which is eight times more than any other high-risk medicine.
Following the inquest, there will be a report issued to prevent future deaths.
Calls for Change:
Sean’s inquest highlighted one of the many issues with clozapine. As a result, Watson Woodhouse are passionate about the effects and complexities of the drug being made public knowledge. Currently, the warning labels on the medication box do not reflect the seriousness of the consequences of taking other substances, such as alcohol, whilst taking clozapine. It is essential that patients and any carers should be made aware of the risks and warnings repeated on a regular basis. Watson Woodhouse are calling for the labels to be changed to clearly identify the risk involved, and that drinking alcohol can be fatal.
Sign the petition to join the calls for change: Petition · Improve the use of Clozapine in the UK – United Kingdom · Change.org
In the media:
Calls for better monitoring of antipsychotic drug linked to hundreds of deaths – Channel 4 News
