Recurring concern

Unreliable metabolic monitoring for patients taking antipsychotic medication

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First reported 2 Dec 2014•Latest report 9 Jul 2015

Definition

What this concern includes

Includes failures of controls specifically dedicated to metabolic monitoring for patients taking antipsychotic medication, including defining required tests and frequency, arranging or completing testing, following up refused or missed tests, reviewing results and escalating abnormal or unresolved monitoring.

Not included

Excludes monitoring of medicines or clinical conditions unrelated to antipsychotic medication and its metabolic risks.
Excludes generic medication review, prescribing, adherence or discharge failures unless they directly concern metabolic monitoring for antipsychotic treatment.
Excludes failures limited to monitoring a different antipsychotic safety domain, such as QTc or blood-level monitoring, unless the assertion also concerns metabolic monitoring.
Excludes failures to act on an abnormal metabolic result when the monitoring process itself was completed reliably.

Reports: 3
Individual concerns: 4
Date range: 2014–2015
Stated actions: 4

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

South London and Maudsley NHS Foundation Trust2

Department of Health and Social Care1

Mother of the deceased1

Partner of the deceased1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

9 Jul2015
Inner South London
Concerns raised2
1. Failure to provide appropriate care plans addressing the risks of refused urine and blood glucose testing
2. Failure to follow up refused glucose and urine testing for patients on antipsychotics
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Testing patients who refuse blood or urine samples is constrained by the practical difficulty and unpleasantness of restraint.
  Stated by South London and Maudsley NHS Foundation TrustUnable to act
AI-generated summary

Michael George · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Michael George died after developing a life-threatening hyperglycaemic condition while receiving long-term Olanzapine treatment. The report identified concerns about inadequate monitoring for diabetes, delays and insufficient urgency in transfer to A&E, incomplete referral information, and gaps in the subsequent oversight and care arrangements for the physical health of mental health inpatients.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide appropriate care plans addressing the risks of refused urine and blood glucose testing
Wider context from the report
“(2) Although there was now systematic recording of urine and blood glucose of patients on antipsychotics on the wards, the audit conducted and presented in court showed a number of patients who had refused these tests, but not demonstrated whether in subsequent weeks testing was conducted or whether these same patients, like Mr George, never had their glucose measured, noting that urine measurement was non invasive, and had an appropriate care plan to address these risks. ”
Source location
Michael George · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to follow up refused glucose and urine testing for patients on antipsychotics
Wider context from the report
“(2) Although there was now systematic recording of urine and blood glucose of patients on antipsychotics on the wards, the audit conducted and presented in court showed a number of patients who had refused these tests, but not demonstrated whether in subsequent weeks testing was conducted or whether these same patients, like Mr George, never had their glucose measured, noting that urine measurement was non invasive, and had an appropriate care plan to address these risks. ”
Source location
Michael George · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Testing patients who refuse blood or urine samples is constrained by the practical difficulty and unpleasantness of restraint.

Verbatim wording from the response
“10. CQUINs (commissioning for quality and innovation) have optimised the requesting of tests on the wards but the management of patients refusing tests is very difficult. It is possible to take glucose under restraint under the MHA. The MCA may be used but, restraint for bloods is technically difficult and if someone has a treatment responsive illness, in the absence of an acute deterioration, people often wait for their mental health to settle and try again once, they regain capacity. If someone is refusing bloods, it is rare for them to agree to urine testing – urine is usually more difficult to get than blood. However with respect to sugar, a BM Stix under restraint is feasible – though not pleasant.”

Source location
2015-0264-Response-by-South-London-and-Maudsley-NHS-Trust
Page 3 · response
Published 9 July 2015
Open published response
13 May2015
North London
Concerns raised1
1. Failure to perform routine blood sugar testing during long-term Clozapine treatment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Share the coroner’s report with NHS England.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

Hana Aisha Abd Elhamid · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Hana Aisha Abd Elhamid was being treated with Clozapine for a mental health condition and developed diabetes, which was likely not identified because routine fasting blood tests were not carried out. She later required intubation for a diabetic coma, self-extubated and sustained airway injury, and died after subsequent breathing difficulties and treatment for a narrowed airway. The principal concerns were the failure to perform routine blood sugar testing and the resulting airway injury during treatment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to perform routine blood sugar testing during long-term Clozapine treatment
Wider context from the report
“that this patient developed diabetes whilst on long term Clozapine treatment and that routine blood tests for sugar in the blood are likely to have prevented events, the need for intubation during treatment for a diabetic coma with resultant trachea injury following self -extubation, that directly led to the patients death ”
Source location
Hana Aisha Abd Elhamid · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Share the coroner’s report with NHS England.

Verbatim wording from the response
“Your report has also been shared with NHS England. NHS England is currently working with the Royal College of Psychiatrists and the Prescribing Observatory for Mental Health to investigate patient safety incidents associated with Clozapine. Patient monitoring is included within the scope of this work. Should compelling evidence of system failures be found, then NHS England would support work to improve management and minimise harm.”

Source location
2015-0194-Response-by-Department-of-Health
Page 2 · response
Published 13 May 2015
Open published response
2 Dec2014
Inner South London
Concerns raised1
1. Lack of mandatory and regular glucose testing for people on antipsychotic medication
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Update the physical healthcare policy to define staff responsibilities and reference Maudsley guidance for patients prescribed Clozapine.
  Stated by South London and Maudsley NHS Foundation TrustStated completed
2. Action
  Audit compliance with physical-health monitoring recommendations and provide feedback to clinical services.
  Stated by South London and Maudsley NHS Foundation TrustStated completed
3. Action
  Review Clozapine clinics across four boroughs to assess operations, resources, responsibilities and functions, define core functions and standards, and clarify management and reporting structures.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
AI-generated summary

Moses Andrew Arthur McDonald · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Moses Andrew Arthur McDonald, who had paranoid schizophrenia and was taking Clozapine, was found deceased at home on 2 April 2013 after experiencing frequent urination and extreme thirst. He had not undergone glucose testing since May 2012. The principal concern was the lack of mandatory and regular glucose testing by the Clozapine clinic while he was receiving antipsychotic medication; the inquest concluded that diabetic ketoacidosis contributed to his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of mandatory and regular glucose testing for people on antipsychotic medication
Wider context from the report
“(1) The lack of mandatory and regular glucose testing while on antipsychotic medication by the Clozapine clinic. ”
Source location
Moses Andrew Arthur McDonald · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update the physical healthcare policy to define staff responsibilities and reference Maudsley guidance for patients prescribed Clozapine.

Verbatim wording from the response
“The current physical healthcare policy has recently been updated and outlines the responsibility of each member of clinical staff to address the physical health needs of all patients.”

Source location
2014-0524-Response-by-South-London-Maudsley-NHS-Trust
Page 1 · response
Published 2 December 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Audit compliance with physical-health monitoring recommendations and provide feedback to clinical services.

Verbatim wording from the response
“In order to monitor compliance with the Maudsley Prescribing Guidelines, specifically relating to the physical health monitoring recommendations the Trust pharmacy team carry out regular audits and feedback to clinical services.”

Source location
2014-0524-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 2 December 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review Clozapine clinics across four boroughs to assess operations, resources, responsibilities and functions, define core functions and standards, and clarify management and reporting structures.

Verbatim wording from the response
“In order to improve consistency of care provision and clarity of roles and responsibilities of physical health monitoring for patients attending the clinic the following actions will be taken within the next 6 months.”

Source location
2014-0524-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 2 December 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to provide appropriate care plans addressing the risks of refused urine and blood glucose testing

Failure to follow up refused glucose and urine testing for patients on antipsychotics

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to perform routine blood sugar testing during long-term Clozapine treatment

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Lack of mandatory and regular glucose testing for people on antipsychotic medication

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions 1

Actions described in response 1

Actions described in response 3