A MAN tragically passed away after suffering a fatal reaction from quitting smoking, an inquest has heard.
Jack Burton, 29, was taking a prescribed antipsychotic medication to treat his schizophrenia, and due to his “heavy “, he was required to take a higher dose of the drug.
Jack Burton, 29, sadly passed away on October 7 2025 Credit: MuchLoved
He took 525mg of clozapine every night, which was the correct dose when he was smoking.
But Jack had been “regularly advised” that stopping smoking would increase clozapine levels in his body.
And while he was on holiday with his family in , in October 2025, he stopped smoking.
Sadly, on October 7 – around three days after quitting – Jack died of clozapine toxicity.
Deborah Lakin, the coroner for , concluded that “it is likely” Jack’s break from smoking “led to a fatal increase in clozapine blood levels”.
In a prevention of future deaths report , the coroner said: “If he had stopped or reduced his smoking he should have informed his psychiatrist to reduce the amount of clozapine he was taking, as this could cause seizures.”
Jack, who lived in Worcester, had a diagnosis of paranoid and was prescribed clozapine by his community psychiatrist.
His sister confirmed to the coroner that he was a heavy smoker but that he had stopped smoking while they were on holiday.
According to the National Institute for Health and Care Excellence (NICE) , smoking cigarettes increases the metabolism of some medicines.
So when smoking is stopped, the dose of these may need to be reduced and the individual should be monitored regularly for adverse effects.
It advises that for people on clozapine, serum drug levels – which show the concentration of medications in the blood – should be monitored before stopping smoking and one week after stopping.
“On stopping smoking, reduce the dose gradually over a week until around 75 per cent of the original dose is reached,” NICE says.
The coroner stressed that “there is a risk that future deaths could occur unless action is taken”.
She raised concerns that there was “no guidance available to doctors” on the relevance of quitting or reducing smoking while on .
Ms Lakin said: “There were inconsistent accounts provided to me by two consultant psychiatrists, about the relevance of reduction in smoking, rather than cessation of smoking, attributable to there being no guidance available to doctors on this issue.
She added: “The evidence revealed that there is no guidance on any standardised practice available to practitioners relating to asking questions and recording answers given when discussing possible symptoms of side effects of the medication.
“Practitioners can therefore make no record if no information is provided, which does not indicate whether questions were asked.”
The coroner commenced her investigation on February 4 2026 and it concluded at the end of the inquest, on May 14.
The coroner’s report was sent to Herefordshire and Worcestershire and Care Trust.
The Sun has approached the Trust for comment.
Eze Chidiebere Paul
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