Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of mandatory glucose testing for antipsychotic patients
The earlier warning
Moses McDonald · 2 Dec 2014 · Lorna Tagliavini, London (Inner South)
“(1) The lack of mandatory and regular glucose testing while on antipsychotic medication by the Clozapine clinic.”
judiciary.uk/prevention-of-future-death-reports/moses-mcdonald
What was promised
Stated action 1 · response to Moses McDonald (2 Dec 2014) · stated 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”
judiciary.uk/…/2014-0524-Response-by-South-London-Maudsley-NHS-…
What recurred
- 9 Jul 2015 · Michael George · Andrew Harris · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Moses McDonald · 2 Dec 2014
“(1) The lack of mandatory and regular glucose testing while on antipsychotic medication by the Clozapine clinic.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.