Lack of mandatory glucose testing for antipsychotic patients
South London and Maudsley NHS Foundation Trust received 2 coroners' reports about this hazard between 2 Dec 2014 and 9 Jul 2015.
They came from 2 different coroners. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“(1) The lack of mandatory and regular glucose testing while on antipsychotic medication by the Clozapine clinic.”
Original on judiciary.uk ↗ South London and Maudsley NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust will carry out a full review of the Clozapine clinics across the 4 boroughs with the aim of: e Reviewing the existing operational processes, resources, management responsibilities and function of the Clozapine clinics in each borough - Croydon, Lewisham, Southwark and Lambeth e Determining the core function of these clinics e Clarifying the management roles, responsibilities and reporting structures within each clinic. e Setting core standards of practice across all 4 boroughs”
Stated timescale: within the next 6 months
- 7 months laterClosely relatedConfidence 0.90 · higha different coroner
“Another (0883-13) following a death from diabetic ketoacidosis, reported the lack of mandatory and regular glucose testing whilst on anti-psychotic medication.”
Original on judiciary.uk ↗ Repeated from the earlier report:lackmandatoryregularglucosetestinganti-psychotic
South London and Maudsley NHS Foundation Trust responded.Response (PDF) ↗
- All reports to South London and Maudsley NHS Foundation Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2014 → 2015Michael George7 months after Moses McDonald · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight the absence of mandatory and regular glucose testing for patients receiving antipsychotic medication. The earlier report focuses on the Clozapine clinic, while the later report concerns antipsychotic use more broadly in the Maudsley Hospital wards.
Moses McDonald · 2 Dec 2014
“(1) The lack of mandatory and regular glucose testing while on antipsychotic medication by the Clozapine clinic.”
Original on judiciary.uk ↗ Michael George · 9 Jul 2015
“Another (0883-13) following a death from diabetic ketoacidosis, reported the lack of mandatory and regular glucose testing whilst on anti-psychotic medication.”
Original on judiciary.uk ↗
Stated action · timescale: within the next 6 months
“The Trust will carry out a full review of the Clozapine clinics across the 4 boroughs with the aim of: e Reviewing the existing operational processes, resources, management responsibilities and function of the Clozapine clinics in each borough - Croydon, Lewisham, Southwark and Lambeth e Determining the core function of these clinics e Clarifying the management roles, responsibilities and reporting structures within each clinic. e Setting core standards of practice across all 4 boroughs”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to South London and Maudsley NHS Foundation Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2014 → 2015 | 0.81 | 0.31 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.