A man with schizophrenia died the day after complaining about feeling dizzy and sick, an inquest into his death heard this week.

Paul Sly, from Princes Risborough, was found on his bedroom floor by staff members at Culverton Court, where he lived, after he did not open his door to take his medication last July.

Culverton Court is specialist housing for people with severe and enduring mental health issues.

The inquest heard he had schizophrenia and was on clozapine and sertraline from his GP to manage his condition.

His clozapine dose was increased from 175mg in 2012, when he was first prescribed the medication, to 350mg when he died.

Dr Miles, who saw Mr Sly several times before his death, told the court: “He was seen at the GP surgery on July 15 and 19 and both of those times, there were no concerns raised.

“He was seen by a care co-ordinator the day before he died. He said he felt his thoughts had improved since the increased dose.

“We would have reviewed him again.”

My Sly had monthly tests at the Whiteleaf Centre, in Aylesbury, to make sure he was on the right dose of clozapine.

But his mother said she felt his dosage had increased “far too quickly”, going up from 200mg in March 2018 to 350mg at the time of his death in July, and questioned why more care had not been taken when he had complained about feeling dizzy and having a raised temperature, as well as diarrhoea, before his death.

Addressing her concerns, Dr Miles said: “We felt his symptoms sounded quite mild. His dose was well within the usual treatment range. There wasn’t enough to raise significant alarms when he came to see us.

“In hindsight if we had known he would die the next day we would have looked into it more but at the time with the information we had we didn’t think it was serious enough.”

He said the trust had launched an investigation into Mr Sly’s death.

Thames Valley Police were called out to Mr Sly’s home just after 10pm on July 26. They said paramedics were already on the scene and, when they entered Mr Sly’s bedroom, they saw him lying on the floor.

Paramedics told officers that Mr Sly was due to take his medication and staff at the home had knocked on his door but he did not open it, forcing them to use the master key to get in.

A toxicology found “higher than therapeutic levels” of clozapine and sertraline “expected in a live person” in Mr Sly’s blood.

Pathologist and toxicologist Dr Mungalsingh also said Mr Sly’s BMI was on the high side – this, combined with his schizophrenia put him at a higher risk of an abnormal heart rhythm, or arrhythmia.

He was also diagnosed with Type 2 diabetes.

The medical cause of death was recorded as clozapine toxicity “on the balance of probabilities”.

Concluding, senior coroner Crispin Butler said there was no evidence of self-harm and that he “favoured the view of the medical experts” who said the cause of death was “most likely to be clozapine toxicity”.

He said: “Mr Sly was last seen alive at 9.30am on the day of his death. On the balance of probabilities, he died as a result of an unintended toxic effect prescribed clozapine.”

He recorded Mr Sly’s death as “drug-related”.