A coroner will warn NHS bosses of the "underappreciated" side effects of an anti-psychotic drug after it was linked to the death of a patient.
Kate Stamp, 30, died of "aspiration pneumonia" after taking Clozapine at The Dene Hospital, West Sussex, in March 2015.
A toxicologist told Crawley Coroner's Court it was "more likely than not" the drug was an underlying cause of death.
It is the third warning from a coroner following deaths involving the drug.
Coroner James Healy-Pratt recorded a narrative verdict, saying the death of Ms Stamp, who had paranoid schizophrenia, was the result of "Clozapine-related hypoxia" and "aspiration pneumonia", contributed to by obesity, smoking and other factors.
He said the side effects of Clozapine "may be rare but they are important," adding that he would write to NHS England "so that awareness is raised".
Ms Stamp had become obese - a known side effect of Clozapine - and developed a persistent chest infection, the court heard.
"More could have been done to monitor her physical health," Sam Cronin, a solicitor at Bindmans, who represented Ms Stamp's family, said.
Ellie Stamp said the family were pleased the coroner sought to raise awareness of the "potentially life-threatening physical effects of Clozapine," adding that "it's possible Kate wouldn't have died" if staff knew at the time.
'An important drug'
In 2018, coroners twice wrote to local NHS authorities - using so-called "reports to prevent future deaths" - after patients died while taking Clozapine.
Julia MacPherson, 54, and Thomas Jackson, 24, both died in 2016.
Dr Billy Boland, of the Royal College of Psychiatrists, said Clozapine was "an important antipsychotic drug" used to treat people who had not responded to at least two other drugs.
However, he said it was "important that lessons are learned" from the "tragic case".
The Priory Group, which took over The Dene after Ms Stamp's death, said: "Many improvements have been made since that time."
It said it would "consider carefully the coroner's comments, particularly around the use of Clozapine, and what lessons can be learned".
NHS England has a legal obligation to respond to a coroner's report within 56 days.