Mr. A was a 49-year-old man of Finnish origin who had been treated in a local nursing home because of behavioral problems associated with moderate mental retardation. Severe aggressive behavior was a major problem in his daily life; therefore, clozapine treatment was started. Clozapine, 450 mg/day, resulted in a marked reduction in his aggressive behavior, but it was discontinued because of agranulocytosis. Mr. A started to suffer from severe recurrent infections, and treatment with granulocyte-colony-stimulating factor gave only temporary benefits. His hematologist concluded that his blood dyscrasia was chronic because his total WBC count fluctuated from 0.5 to 1.5 × 10⁹/liter (normal WBC count range=4.0–10.0 × 10⁹/liter). At that time, it was decided to administer palliative treatment in the familiar environment of his nursing home. Mr. A’s prognosis did not improve, and he died a few weeks later. A forensic autopsy concluded the cause of death to be clozapine-induced myelodysplasia of the bone narrow. Because of a complaint by a relative, the National Authority for Medico-Legal Affairs asked for an expert’s opinion on whether the pharmacological treatment was adequately administered.