Conrad Colson
26 May 2023 · Coroner Nadia Persaud · East London
The coroner's concerns
1. lack of liaison between specialist CADAT and stepdown services
“absence of liaison between the highly specialist services of the CADAT team and the stepdown services provided by NELFT”
2. lack of risk communication to aesthetic dermatology clinic
“neither service adequately highlighted the risks of accessing such treatment to [the deceased] or attempted to share information with the skin clinic”
3. lack of BDD training for step-down teams
“need for training to be provided to step-down service teams in relation to the diagnosis of BDD and the risks associated with it”
4. insufficient national resources for BDD
“lack of national resources for BDD”
Responses
2023-0173-Response-from-Aesthetic-Dermatology.pdf ↗· NHS England and Tatiana Aesthetic Dermatology Clinic
2023-0173-Response-from-NELFT.pdf ↗· Royal College of Psychiatrists
Stated action · 05/07/2023
“Learning event to be arranged on this case with specific reference services were aware BDD for all staff on BDD and the importance of working with partner agencies.”
Stated action · 30/09/2024
“The Trust is planning to undertake a Quality Improvement Project on understanding why there are gaps in risk assessment and risk of accessing such management processes (a couple of examples of reoccurring treatment to [the deceased] themes), particularly when there are poor outcomes associated 30/09/2024 Assistant or attempted to share with care provided.”
Stated action · 01/12/2023
“Training department to arrange training on BDD for all staff this 01/12/2023 heard that there is a (BDD) training to to be in conjunction with SLAM who offer training in this need for training to be be offered to all specialised area.”
2023-0173-Response-from-NHS-England.pdf ↗· NHS England and Tatiana Aesthetic Dermatology Clinic
2023-0173-Response-from-South-London-and-Maudsley-NHS-Foundation-Trust.pdf ↗· South London and Maudsley NHS Foundation Trust
Stated action · 1 June 2023
“The updated CADAT discharge policy also includes how staff are expected to communicate with skin clinics regarding patients seeking aesthetic dermatological/cosmetic treatment which includes seeking consent from the patient to liaise with local services/GP, and if this is refused how to manage the situation.”