At both primary and secondary health levels it appeared to have been the view that following initial titration and a period of regular checks, annual monitoring for signs of the development of diabetes should be carried out annually as recommended in NICE guideline CG178. However, expert evidence at the inquest suggested that in cases of individuals with a higher risk of developing diabetes, more regular checks were called for. Further there was evidence to the effect that the results of relevant physical healthcare checks had not been shared between primary and secondary healthcare providers. Thus: (1) draw to the attention of the National Institute for Health and Care Excellence their guidance CG1ZBand specifically clause L364thereof andask them to consider Wiltshire & Swindon Coroner'$ Office; 26 Endless Street; Salisbury, Wiltshire; SPI IDP Tel 01722 438900 Fax 01722 332223 1st whether to the directive for an annual test of inter alia HbATC, there might be added the words: "or more frequently in those who have a higher baseline risk for the development of diabetes" (2) draw to the attention of Avon and Wiltshire Mental Health Partnership NHS Trust with reference to their planned review of their document entitled Medicines Guideline: Monitoring psychotropic medication" my first paragraph addressed to the National Institute for Health and Care Excellence and ask them to consider adding similar wording to their recommendations with regard to annual review appearing at page 4 of the present document: Secondly, ask the Trust to consider adding advice in the document to the effect that when a patient is prescribed anti-psychotic medication contact be made with the patient's GP practice (a) informing them of this fact (b) requesting communication thereafter of any physical health findings that might indicate serious side-effects or potential side-effects of the drugs and (c) communicating any relevant physical health findings to the GP practice as well as mental health findings.