Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0219, written 26 Jul 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jul 2017 |
|---|---|
| Reference | 2017-0219 |
| Deceased | Songul Bozdag |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Songul BOZDAG (died 09.02.17)
THIS REPORT IS BEING SENT TO:
1.
Medical Director
East London NHS Foundation Trust
Trust Headquarters
9 Alie Street
London E1 8DE
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 13 February 2017, one of my assistant coroners, Heather Williams,
commenced an investigation into the death of Songul Bozdag, aged 36
years. The investigation concluded at the end of the inquest on 24 July.
I made a determination of suicide, when Ms Bozdag, who suffered from
schizophrenia, jumped from a tenth floor window of Massey House,
Violet Road, London, at approximately 11.20am on 9 February 2017.
4
CIRCUMSTANCES OF THE DEATH
Ms Bozdag had been under the care of mental health services for
approximately twelve years before her death. As well as schizophrenia,
she had been diagnosed with recurrent depressive disorder, obsessive
compulsive disorder symptoms and psychotic symptoms.
1
Her last inpatient admission was on 29 June 2016 to Brick Lane Ward of
Tower Hamlets Centre for Mental Health, initially informally but later
detained under section 3 of the Mental Health Act. She was discharged
from the ward on 23 August 2016, and last seen for review by her
psychiatrist and care co-ordinator on 8 February 2017, which was the
day before she died.
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 Bozdag’s care co-ordinator did not arrange for what was a
mandatory seven day review of Ms Bozdag after discharge from
hospital in August/September 2016.
2. She recorded monthly reviews of Ms Bozdag on only half of the
months from September 2016 to Ms Bozdag’s death in February
2017, though monthly reviews were mandatory.
3. The care co-ordinator gave evidence at inquest that she had
actually reviewed Ms Bozdag once a fortnight when Ms Bozdag
came for her depot injections, but in the main did not record these
discussions. She did include in her statement for the court one
note recording the nature of a discussion had on 10 February.
This was in fact the day after death. She said this was an error.
4. She described having a very good recollection of individual
consultations with Ms Bozdag, such as one on 6 September 2016
though there was no record supporting this description. However,
she had not had a sufficient recollection of Ms Bozdag’s treatment
during her life to notice that the need for a care plan approach
(CPA) had not been recorded on the computer system.
5. Finally, the care co-ordinator did not ensure that the drug card in
use reflected the psychiatrist’s increased prescription of 50mg of
risperidone rather than the original one of 37.5mg. Ms Bozdag
was therefore under medicated on an ongoing basis.
These were the errors of an individual, but there is an additional point
that they were not captured by any sort of system safety net during Ms
Bozdag’s life.
2
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 the report, namely by 26 September 2017. 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 Mark Lucraft QC, the Chief Coroner of England & Wales
, consultant psychiatrist
care co-ordinator
, husband of Songul Bozdag
, niece of Songul Bozdag
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 find it useful or of 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.
9
DATE SIGNED BY SENIOR CORONER
26.07.17
3
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.
East London NHS Foundation Trust Please a to: Associate Director of Legal Affairs Trust Headquarters 9 Alie Street London E1 8DE Telephone: 020 3738 7253 6" November 2017 Senior Coroner M E Hassell Inner North London Poplar Coroner’s Court 127 Poplar High Street London E14 0AE Dear Madam Inquest touching upon the death of Songul Bozdag This is a formal response to your Regulation 28 Report dated 8" August in which you set out your concerns relating to the care Ms Bozdag received from East London NHS Foundation Trust. | am aware that during the course of the Inquest you heard evidence from Ms Bozdag’s care coordinator that led you to have concerns about the systems in place at the CMHT to monitor the work of care coordinators. Before setting out the steps that the Trust is taken in relation to improving systems | would like to reassure you that the issues highlighted in relation to the conduct of the care co-ordinator. One of the first actions taken was an audit of the care coordinators case load to ascertain if she was working to agreed record keeping standards and practice. The gaps in the care that she provided to Ms Bozdag are currently being dealt with by her employer, the London Borough of Tower Hamlets, through formal processes with the full support of the Trust and the individual in question is not working with patients whilst these processes are ongoing. In relation to systems within the Community Mental Health Team (CMHT) it is acknowledged that during 2016 and early 2017 the leadership and oversight was compromised and significant work has been undertaken to improve this position. There is now a new Operational Team Lead in post and this member of staff has imbedded robust systems within the CMHT. The first change is the implementation of an Inbox based system to communicate discharge care plans to CMHT staff. Po Chief Executive: Dr Navina Evans This system will ensure that details of patient discharges, including discharge plans, are sent from wards to Community Mental Health Teams through a central email referrals inbox. The system will enable oversight of care plans, including medication changes. The Inbox is managed by a Duty Administrator within the CMHT who is rostered daily and reviews all incoming mail during the day and is overseen by a senior practitioner in each team along with the lead administrator. A seven day follow up following discharge from hospital is a key intervention and has now been extended to include all individuals following discharge from hospital, not just those under the Care Programme Approach. Senior Practitioners are now responsible for ensuring that actions arising from discharge plans are allocated to care coordinators and monitored to ensure they have been followed up. This will include seven day follow ups, medical reviews and changes in medication. This new process will also allow senior practitioners to allocate actions to a duty worker if the care coordinator is absent from work or unable to undertake an intervention for any reason. The key system for monitoring the ongoing support provided to service users by a care coordinator is monthly supervision. This had not been robustly undertaken within the CMHT and | am pleased to report that this is now working in line with Trust procedures with all care coordinators receiving monthly supervision. Standing agenda items in supervision include CPA status, delivery of the care plan including monitoring of visits and medical reviews and the standard to record keeping. Regular audits are being undertaken to maintain a robust oversight on the process and also actively respond to any gaps in the system in a timely way and to provide assurance that staff are working to agreed record keeping standards and practice. In addition to the above a review of internal monitoring process has been undertaken to assure the Trust that systems are sufficiently robust and will flag up any cases where service users on CPA are not being seen regularly or reviewed by their consultant. Teams have access to live reports which allows real time activity by the Team and can be drilled down to provide data on an individual service user. The Team administrator also sends out weekly prompts around key performance indicators to the Operational Team Lead and this includes activity for patients on CPA. With the systems that are now implemented at the CMHT | hope you will be content that the Trust has taken these issues seriously and adequately addressed your concerns. If you do require any further information please do not hesitate to contact me. Yours faithfully = enc; Be Officer po Chief Executive: Dr Navina Evans
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