South London and Maudsley NHS Foundation Trust

“The Trust's AWOL Policy now mandates that a Multi-Disciplinary Team (MDT) risk assessment must be conducted following every Absence Without Leave (AWOL) incident. The Responsible Clinician is required to promptly review the patient's leave status thereafter.”

“The updated CADAT discharge policy also includes how staff are expected to communicate with skin clinics regarding patients seeking aesthetic dermatological/cosmetic treatment which includes seeking consent from the patient to liaise with local services/GP, and if this is refused how to manage the situation.”

“Learning event to be arranged on this case with specific reference services were aware BDD for all staff on BDD and the importance of working with partner agencies.”

“The Trust is planning to undertake a Quality Improvement Project on understanding why there are gaps in risk assessment and risk of accessing such management processes (a couple of examples of reoccurring treatment to [the deceased] themes), particularly when there are poor outcomes associated 30/09/2024 Assistant or attempted to share with care provided.”

“Training department to arrange training on BDD for all staff this 01/12/2023 heard that there is a (BDD) training to to be in conjunction with SLAM who offer training in this need for training to be be offered to all specialised area.”

“we will add a side-effect of suicidal ideation to the lamotrigine monograph in the BNF. We will also add information on this side-effect to the important safety section of the lamotrigine monograph.”

“Monitoring of training logs for all professional groups When reviewing a Team, Inpatient or CMHT falls below 50% of Place on risk Tier 1 training.”

“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”

“The Trust's policy on risk assessment is clear in its documentation and staff have been reminded to ensure that when risk is assessed, that this is documented in the correct fashion in the relevant section of the electronic patient record to ensure that this is easily accessible by all clinical staff.”