PFD report

Moses Andrew Arthur McDonald · Prevention of Future Deaths report

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Issued 2 Dec 2014•Inner South London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of mandatory and regular glucose testing for people on antipsychotic medication
    Part of recurring concern: Unreliable metabolic monitoring for patients taking antipsychotic medication
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Action

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

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 December 2014.
  2. 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 completedThe respondent said that this action was complete when they made their response on 2 December 2014.
  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 plannedThe respondent said that this action was planned when they made their response on 2 December 2014.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Unreliable metabolic monitoring for patients taking antipsychotic medication.

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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

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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

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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

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Maintain team processes for discussing, reviewing and escalating medication-related adverse effects through planning meetings, clinical meetings and supervision.

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 December 2014.
  2. 2

    Provide regular learning-lesson feedback to clinical staff through forums representing all pathways and boroughs.

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 December 2014.
  3. 3

    Provide medication-management training incorporating Clozapine policy and practice guidance for Adult Mental Health clinical staff.

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 December 2014.
  4. 4

    Identify physical-health leads in all Promoting Recovery teams to improve standards and ensure audits are completed and acted upon routinely.

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 December 2014.

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

Maintain team processes for discussing, reviewing and escalating medication-related adverse effects through planning meetings, clinical meetings and supervision.

Verbatim wording from the response

“There are robust team processes in place in all teams across the AMH pathway which includes daily planning meetings, clinical formation meetings and monthly clinical supervision where it is expected that clinical staff discuss, review and raise concerns about any patient who may be experiencing adverse effects from their medication including Clozapine.”

Source location

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

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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

Provide regular learning-lesson feedback to clinical staff through forums representing all pathways and boroughs.

Verbatim wording from the response

“In addition in order to learn lessons from previous incidents clinical staff now receives regular feedback from the monthly learning lessons forums. These forums have representation from all pathways and boroughs.”

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

Provide medication-management training incorporating Clozapine policy and practice guidance for Adult Mental Health clinical staff.

Verbatim wording from the response

“Specifically within the Adult Mental Health pathway (AMH) the Trust provides training for clinical staff on medication management. Trainers have recently incorporated specific training for staff on Clozapine management covering issues relating to Trust policy and practice guidance.”

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

Identify physical-health leads in all Promoting Recovery teams to improve standards and ensure audits are completed and acted upon routinely.

Verbatim wording from the response

“All Promoting Recovery teams have now identified physical healthcare leads whose remit include improving and maintaining standards and ensuring physical healthcare audits are completed and acted upon routinely.”

Source location

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

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026