“The nurse said I had to go through my health check results with you — is it bad news?”

An SMI physical health check is not a box-ticking exercise: the most dangerous finding here was not in the bloods but in a change the record did not show. Smoking induces the liver enzyme CYP1A2, which clears clozapine; stopping smoking (vapes and nicotine replacement do not induce it) can raise clozapine levels substantially within days to two weeks, causing sedation, hypersalivation, ataxia, myoclonus and seizures, and worsening clozapine-induced gastrointestinal hypomotility — a potentially fatal adverse effect that needs active laxative treatment (stimulant plus softener) and urgent assessment if there is pain, distension, vomiting or absent flatus. The right response is to support the quit, contact the clozapine clinic the same day for a level and dose review, and never advise restarting smoking. Then complete the cardiometabolic work: people with SMI die 15–20 years earlier, mostly from cardiovascular disease; QRISK3 includes SMI and antipsychotic use, so offer atorvastatin 20 mg at 10% or more, refer non-diabetic hyperglycaemia to the Diabetes Prevention Programme, address diet (sugary drinks) and weight, and share the plan with the mental health team.