Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0560, written 24 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Nov 2014 |
|---|---|
| Reference | 2014-0560 |
| Deceased | Sandra Bodrozic |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
Camden and Islington INHS| NHS Foundation Trust Executive office 4" Floor, East Wing St Pancras Hospital 4 St Pancras Way LONDON NW1 OPE Fax: www.candi.nhs.uk Date: 15" January 2015 Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Dear Coroner Hassell, Re: Ms Sandra Bodrozic (date of death: 29°" June 2014) | write further to your report on 24° November 2014 in which you highlighted concerns about the care delivered by the Camden & Islington Foundation Trust (the Trust) to Ms Bodrozic. | wish to thank you for bringing your concerns to our attention and | am writing to address the issues you have raised below and give the Trust’s assurance that it has reviewed these matters and will continue to do so. In your report you state that, “during the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.” You outlined your concerns in three areas: Ms Bodrozic agreed on 23" May to the recommendation of those treating her that she be admitted to hospital on an informal basis. However, no bed was found for her until 30" May, by which time she had changed her mind. There was no exploration of purchasing a bed from the private sector when no NHS bed was available. The Consultant Psychiatrist treating Ms Bodrozic formed the view that on the evening of 18" June that Ms Bodrozic should have a mental health assessment however, however, the psychiatrist was going on holiday the next day and so decided to leave this until her return, rather than asking colleagues. The approved Mental Health Professional (AMHP), a social worker, who visited Ms Bodrozic on Wednesday 24" June 2014 decided she needed a mental health act assessment and Chair: Leisha Fullick Your partner in CRI Chief Executive: Wendy Wallace care & improvement 2a C&L i NHS Foundation Trust iding treat it and social fe tal ill-health FCamden ISLINGTON wand substance misuse in adults in partnership with Camden and isfington councils, NHS immediately made the appropriate referral. However once the referral was made, it took until the following week for this to be arranged and Ms Bodrozic had killed herself in the meantime, on Sunday 29"" June. Health Care professionals explained in court that Mental Health Act (MHA) assessments are, by their very nature, urgent, but there seemed to be a their general acceptance by the team that they will usually take several days to take place, in this case from a Wednesday until the following Tuesday. The provision for assessment is open ended, with no apparent sense of urgency, and there is no protocol for the timeframe within which this should take place, nor is a time agreed as appropriate with patient or family Ms Bodrozic’s family were not told that, realistically, they could only obtain and immediate assessment by attending a hospital emergency unit. The Trust’s response to each point: 1. When took the decision to admit Ms Bodrozic to hospital on an informal basis on 23 May 2014 she spoke to the duty nurse at the Highgate Mental Health Centre (the Centre) to make the referral. They discussed the urgency of the referral and although there was no bed available at the Centre it was anticipated that a bed would become available within the next few days. This was appropriate given the clinical urgency of the case at the time. Therefore, a private bed was not considered to be necessary. The family had been advised that they could take Ms Bodrozic to the Accident & Emergency department over the bank holiday weekend if there were any changes in her state of mind or behaviour. It was thought that a bed was going to be available on 27" May at 2.00pm, but this turned out to be incorrect. Ms Bodrozic medical notes document that the North Camden Recovery & Rehabilitation Intake Team (the Intake Team), were in contact with the duty nurse as agreed on a daily basis. A bed became available on 29" May and the Intake team made several attempts on that day to contact Ms Bodrozic about the bed. They did not manage to meet or speak to her. Another bed was arranged on 30 May 2014 and Ms Bodrozic’s brother was contacted and he spoke to her. He reported back to the Intake Team that Ms Bodrozic was now refusing admission. There had been no discussion about finding a private bed rather than a Trust bed because the availability of Trust beds at the Centre was changing daily and there had been an expectation that one would become available within the timescale needed. The Serious Incident Report in relation to Ms Bodrozic’s death noted that the Trust’s bed management policy was not followed correctly. Consequently, the Clinical Director for the Acute Division has clarified and disseminate the Trust’s bed management policy to its employees emphasising that, ‘any patient requiring a bed will be offered admission regardless of their Mental Health Act status’. This should ensure that private beds are available to informal patients promptly. INHS| 2. The Consultant Psychiatrist treating Ms Bodrozic had established a good rapport with her and her family and had made stringent efforts to engage Ms Bodrozic in her care. She felt that it was a reasonable clinical decision to carry out the MHA assessment following her period of leave. Whilst on leave, clinical cover arrangements were in place with another Consultant Psychiatrist, which is the usual procedure in order to continue to provide support to Ms Bodrozic and her family should he need arise. Ms Bodrozic brother contacted the team on 24" June expressing concerns about his sister’s mental health and following a home visit by the social worker, a referral for a MHA assessment was made. The social worker advised that the assessment would most likely take place the following week but in the meantime, if more urgent care was required, Ms Bodrozic or her family could contact the Crisis Team or attend the Emergency Department. 3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions: a) Family members are to be kept informed by community services and the AMHP service as to when an assessment is likely to take place with specific attention paid to the carer and how safe they feel with the person they care for. b The AMHP will also record on the electronic patient record system (RiO) how the risks for any delays will be mitigated. c) Delays caused by other agencies being unable to attend will be escalated to senior management and if recurrent put on the Trust risk register. d An alert to delays by the London Ambulance Service to attend MHA assessments have been made to the Joint Commissioner in Camden, and also of the poor attendance of GP’s to MHA assessments with the Joint Commissioners in the London Borough of Islington. | hope that the issues outlined above satisfactorily address the concerns raised. Yours sincerely, Wendy Wallace Chief Executive
Regulation 28: Prevention of Future Deaths report
Sandra BODROŽIC’ (died 29.06.14)
THIS REPORT IS BEING SENT TO:
1. Ms Wendy Wallace
Chief Executive
Camden & Islington NHS Foundation Trust
4th Floor, East Wing
St Pancras Hospital
4 St Pancras Way
London NW1 0PE
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 7 July 2014, I commenced an investigation into the death of Sandra
Bodrožic’, aged 39 years. The investigation concluded at the end of the
inquest on 17 November 2014. I made a determination at inquest that Ms
Bodrožic’ took her own life, whilst suffering a schizoaffective disorder.
4
CIRCUMSTANCES OF THE DEATH
Sandra Bodrožic’ was at home with her mother when she suddenly ran
up to the attic, said goodbye and jumped out of the window, landing on
the ground three storeys below.
1
Ms Bodrožic’ had been detained under the Mental Health Act on 22
October 2013 and admitted to St Pancras Hospital. She was discharged
on 11 February 2014 then treated in the community until her death.
5
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed matters giving
rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances, it is my statutory duty to
report to you.
The MATTERS OF CONCERN are as follows.
1. Ms Bodrožic’ agreed on 23 May 2014 to the recommendation of
those treating her that she be admitted to hospital on an informal
basis. However, no bed was found for her until 30 May, by which
time she had changed her mind.
There was no exploration of the possibility of purchasing a bed
from the private sector when no NHS bed was available.
2. The consultant psychiatrist treating Ms Bodrožic’ formed the view
on the evening of 18 June 2014 that Ms Bodrožic’ should have a
Mental Health Act assessment. However, the psychiatrist was
going on holiday the following day and so decided to leave this
until her return, rather than asking colleagues.
3. The approved mental health professional (AMHP), a social worker,
who visited Ms Bodrožic’ on Wednesday, 25 June 2014, decided
that she needed a Mental Health Act assessment and immediately
made the appropriate referral.
However, once the referral was made, it took until the following
week for this to be arranged, and Ms Bodrožic’ had killed herself in
the meantime, on Sunday, 29 June.
Healthcare professionals explained in court that Mental Health Act
assessments are, by their very nature, urgent, yet there seemed to
be a general acceptance by the team that they will usually take
several days to take place, in this case from a Wednesday until the
following Tuesday.
The provision for assessment is open ended, with no apparent
sense of urgency, and there is no protocol for the timeframe within
which this should take place, nor is a time agreed as appropriate
with patient or family.
2
Ms Bodrožic’s family were not told that, realistically, they could
only obtain an immediate assessment by attending a hospital
emergency unit.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your organisation have the power to take such
action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 26 January 2015. I, the coroner, may extend the
period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise you must explain
why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Care Quality Commission for England
,
brother and sister of Sandra Bodrožic’
I am also under a duty to send the Chief Coroner a copy of your
response.
The Chief Coroner may publish either or both in a complete or redacted
or summary form. He may send a copy of this report to any person who
he believes may
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
24.11.14
3
‘ REGULATION 28; REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Norfolk & Suffolk NHS Foundation Trust Trust Headquarters Hellesdon Hospital Drayton High Road Norwich NR6 5BE CORONER | am JACQUELINE LAKE, senior coroner, for the coroner area of NORFOLK CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29. of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 3 June 2014 I commenced an investigation into the death of JO ANNE CAROL NOBBS, AGED 36 years. The investigation concluded at the end of the inquest on 3 December 2014. The conclusion of the inquest was Medical Cause of Death: Unascertained. Short Form Conclusion: Open. CIRCUMSTANCES OF THE DEATH Miss Nobbs had long standing physical problems and mental health issues. She was diagnosed in 2009 with Borderline Personality Disorder. She did not always engage with professionals. From January 2014 her GP and.sister noted deterioration in her mental health. In February 2014 she began to disengage from the various professionals, although continued to self refer to hospital for a variety of physical symptoms. The Community Mental Health Team tried contacting her on a number of occasions from March up to the date of her death with no success. She stopped collecting her medications on’8 May 2014. Her GP and the Pharmacy called Police to carry outa welfare check on 30 May 2014. Police found her dead in her home on 2 June 2014. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) A correlation between Miss Nobbs’ deteriorating physical health and her deteriorating mental health was noted by some mental heaith professionals and documented in her mental health records but this was not investigated or acted upon by other mental heaith professionals, despite Miss Nobbs attending at A & E Department, Norfolk & Norwich University Hospital on at least 10 occasions between January and March 2014 presenting with a variety of symptoms and at varying times of day and night (2) A Care Plan was put in place in January 2014 of steps to be taken on the basis that Miss Nobbs was going to engage with mental health services. The evidence is that this plan was kept under review and was a “continuing” plan. There is no documentation supporting such a continuing plan, particularly when Miss Nobbs was no longer | ~ engaging with mental health services. She had not been seen on a 1:1 basis since before 26" February 2014 by any of the Community Mental Health Team, save in respect of a believed sighting in the street. There is no evidence of a revised Care Plan being put in place, save in respect of continuing to try to make contact with Miss Nobbs. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. You are under a duty to respond to this report within 56 days of the date of this report, namely by 29 January 2015, | the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION lL have sent a copy of my report to the Chief Coroner and to the following Interested Persons lam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He.may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your tesponse, about the release or the publication of your response by the Chief Coroner. 4 December 2014 sannnesaetvCesrensranessteanenenaatans Jacqueline Lake YOUR RESPONSE Senior Coroner for Norfolk
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Norfolk and Suffolk AVF NHS Foundation Trust Trust Management 4" Floor Admin Hellesdon Hospital Drayton High Road Hellesdon Norwich 2.8 JANI NR6 5BE Tel: 01603 421102 Fax: 01603 421118 Our ref.ml/mp 21 January 2015 Ms J Lake HM Coroner Norfolk Coroner's Service 69-75 Thorpe Road Norwich Norfolk NR1 1UA Dear Ms Lake Regulation 28 report following the inquest of Ms Jo Anne Nobbs on 3 December 2014 | write in response to your report dated 4 December 2014. Under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust consider issues of service delivery following the conclusion of the inquest into the death of Ms Jo Anne Nobbs on 3 December 2014. You identified a matter of concern relating to a correlation between Miss Nobbs’ deteriorating physical and mental health, observing this was noted by some professionals but not investigated by the mental health team. This was despite Miss Nobbs attending the A& E department at Norfolk and Norwich University NHS Foundation Trust on at least 10 occasions between January and March 2014. The reason for this was 3 that. the Community. Mental Health Team v was unaware of the frequency of Ms Nobbs"attendance at the acute hospital during this period. It is understood these attendances were in relation to her physical health and the acute hospital may not have assessed there to be a potential mental health need. Where an individual presents at the acute general hospital and there are possible mental health needs the Trust has an established Psychiatric Liaison Service, based in the hospital, to assist with assessment. In completing an assessment the Psychiatric Liaison Service can signpost patients to a range of services or refer them into the Trust's secondary care teams. They provide the GP and the Community Mental Health Team with a record of their contact. The Liaison Service saw Ms Nobbs on single occasions in 2012, 2013 and on 6 January 2014 following referral from the acute hospital. Given thé ‘tack of contact with’ Ms Nobbs, the care coordinator was in the process of arranging a professionals meeting to consider next interventions, when they were informed of her death. at ABO, Chair: Gary E Page ~~ ese WAS Chief Executive: Michael Scott . 3 & MINDFUL Trust Headquarters: Hellesdon Hospital, St iT] = é EMPLOYER i onewa 9 Drayton High Road, Norwich, NR6 5BE DIVERSITY CHAMPION “2syy% Tel: 01603 421421 Fax: 01603 421440 www.nsft.nhs.uk id . a isan Tel: 01603 421421 Fax: 01603 421440 www.nsft.nhs.uk jef E tive: Michael Scott V/s MINDFUL Chief Executive: Michael Sco , x; Trust Headquarters: Hellesdon Hospital, KK s nN u iq p Stonewall Ms Lake -2- You additionally raised the concern regarding the absence of a changing plan when Miss Nobbs disengaged from services from March 2014 onwards. Notably, Miss Nobbs was not seen by the team from March to her death in June, save for a sighting of her in May by one of the team's support workers. . be The Trust's internal investigation identified this was a matter of concern observing the clinical team did not follow Trust policy. This policy provides guidance for staff in the event of missed or cancelled appointments. The report made recommendation that work was undertaken with the team to improve this area of practice. | confirm the team have completed the recommendation. They have been refreshed on the Policy and provided evidence they are discussing missed appointments in their weekly clinical team meetings. We will be sharing this learning more widely within the Trust, via our Patient Safety Newsletter and internal forums. If | can be of any further assistance please do not hesitate to contact me. Yours sincerely NZ Michael Scott Chief Executive ABO, Chair: Gary E Page Drayton High Road, Norwich, NR6 5BE DIVERSITY CHAMPION
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