Coroner Deborah Lakin wrote that Mr Burton, who had been a heavy smoker, was taking the prescribed 525mg Clozapine nightly which was the correct dose when he is smoking. But the coroner said Mr Burton, from Worcester, had been “regularly advised that any cessation of smoking would increase Clozapine levels” and did not smoke while he was on holiday in Scarborough. She said Mr Burton stopped smoking tobacco on or before October 4, 2025, and “it is likely that this led to a fatal increase in Clozapine blood levels”. In a narrative conclusion at an inquest, the coroner found that Mr Burton died of Clozapine toxicity. A Herefordshire and Worcestershire Health and Care NHS Trust spokesperson said it has reviewed its “smoking cessation and clozapine monitoring policies” after Mr Burton’s death.