Dear Ms Tagliavini, Re Moses Andrew Arthur McDonald, Died 2"d April 2013, Case Ref: 883-2013 write in response to the Regulation 28 Report (o Prevent Future Deaths dated 2nd December 2014, which you sent following the Inquest into the death of Mr McDonald; In the report, you raised concerns relating to the lack of mandatory and regular glucose while on antipsychotic medication by the Clozapine clinic. My response and details of actions taken by the Trust are listed below. Glucose Testing for Patients Prescribed Anti-Psychotic Medication 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 , The Trust publishes the Maudsley Prescribing Guidelines, which is used throughout the UK and internationally as guidance for prescribers. The physical healthcare policy includes reference to these guidelines for those patients who are prescribed Clozapine. Ideal monitoring would include a fasting blood glucose 0 glucose tolerance test afler a month; then every 4-6 months The recommended minimum monitoring is a urine glucose and random blood glucose before Clozapine is started, and repeated every 12 months, with regular monitoring of symptoms of fatigue, thirst, polyuria and candida infection; The Trust considers this monitoring a8 essential for patients on Clozapine. The policy also outlines the expectation that all patients prescribed anti LTagliavini Ref: 883+2043 MAA McD - 30.0L.15 Www,slam nhs uk 30"h testing

psychotic medication, which has the potential to impact o their physical health, should have a physical health care plan, 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. 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 0 Clozapine management covering issues relating to Trust policy and practice guidance. 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. There are robust team processes in place in all tearns 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. In addition in order to Iearn lessons from previous incidents clinical staff now receives regular feedback from the monthly learning lessons forums. These forums have representation fiom all pathways boroughs Function of the Clozapine Clinic The Trust, having reviewed the situation, has found that Clozapine clinics across the Trust operate differently in each Borough and there is a lack of clarity and consistency in relation to operational processes, resources, management responsibilities and function of these clinics 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_ The Trust will carry ut a full revicw of the Clozapine clinics across the 4 boroughs with the aim of: Reviewing the existing operational processes, resources, management responsibilities and function of the Clozapine clinics in each borough Croydon; Lewisham; Southwark and Lambeth Determining the core finction of these clinics Clarifying the management roles, responsibilities and reporting structures within each clinic. Setting core standards of practice across all 4 boroughs Progress will be monitored and reported through the Trust Physical Healthcare committee and issues escalated as necessary to the Trust Quality Sub Committee. LTagliavini - Ref: 883-2013 MAA McD - 30.01.15

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that this letter addresses the issues that You have raised and I would like to thank you bringing yOur concerns to my attention;