Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0277, written 5 Sep 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Sep 2022 |
|---|---|
| Reference | 2022-0277 |
| Deceased | Demet Akcicek |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Alcohol, drug and medication related deaths · Mental Health related deaths |
| 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
Demet AKCICEK (died 27.05.22)
THIS REPORT IS BEING SENT TO:
1.
Chief Executive
Camden & Islington NHS Foundation Trust (C&I)
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 4 April 2022, I commenced an investigation into the death of Demet
Akcicek, aged 41 years. The investigation concluded at the end of the
inquest on 5 September 2022. I made a determination at inquest as
follows.
Demet Akcicek died as a result of taking an excess of medication that
was both prescribed for her, and obtained by her online.
She had suffered long term post traumatic stress disorder and
depression, and had become dependent upon
.
She did not intend to take her life.
1
4
CIRCUMSTANCES OF THE DEATH
Ms Akcicek was found on the morning of 27 May 2022 by her partner, in
bed with their 7 year old son. She had died in the night beside her
sleeping child.
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.
When the duty worker from Islington complex depression, anxiety and
trauma (CDAT) service rang Ms Akcicek for a welfare check on 25
November 2021, Ms Akcicek reported feeling “quite bad” and that she
wanted to cry. She explained that she had difficulty performing everyday
activities such as cooking and taking her child to school. She said that
two nights earlier, her son reported that she had woken chanting, “I don’t
want to die, I don’t want to die”.
The duty worker (a registered mental health nurse) formed the view that
Ms Akcicek needed to be seen by the service, but failed to put her name
on the board, and so she was not discussed at the multi disciplinary team
meeting and no follow up was arranged. In addition, the duty worker
accepted in court that her note of the conversation was insufficient. I
found the note difficult to understand and the duty worker was not able
fully to explain its meaning.
The duty worker told me that she will not make such mistakes again.
However, I did not hear evidence of what steps, if any, Camden &
Islington Trust has taken to avoid such a situation arising in future.
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 this report, namely by 7 November 2023. I, the coroner, may extend
the period.
2
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 Thomas Teague QC, the Chief Coroner of England & Wales
, partner of Demet Akcicek
I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I
believe may find it useful or of interest.
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 response, about
the release or the publication of your response.
9
DATE SIGNED BY SENIOR CORONER
07.09.22 ME Hassell
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.
Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Executive Office 4th Floor, East Wing St Pancras Hospital 4 St Pancras Way London NW1 0PE 3rd November 2022 Dear Coroner Hassell Re Prevention of Future Deaths report – Demet Akcicek I am writing further to this inquest which took place on 5th September 2022. You issued a regulation 28 report in regard to the following issues; after a telephone conversation with Ms Akcicek from which it was agreed that follow up was required, the duty worker from the Complex Depression Anxiety and Trauma Team (CDAT) failed to write Ms Akcicek’s name on the board, which meant that she was not discussed at the multidisciplinary team meeting and no follow up was arranged. The duty worker accepted in court that her note of the conversation was insufficient. She assured the court that she personally would not make such a mistake again, but you did not hear evidence as to what the Trust has done to prevent such a situation arising in future. Firstly I would like to offer sincere apologies to Ms Akcicek’s family on behalf of both the CDAT team and the Trust for this error which led to her not being followed up by the team. In order to address this and prevent it happening again, the team manager and service manager have updated the CDAT Operational Policy and have implemented a daily duty sheet/tracker. All matters dealt with on duty are logged immediately on this sheet which are then cross checked at 4.30pm daily by the senior on duty to handover and ensure appropriate follow up for all issues logged. A copy of the amended Operational policy incorporating this new process is enclosed with this response. This new process has been discussed at the team business meeting and was officially started on 24th October. It will be reviewed in 6 weeks’ time and monitored going forward through audit and governance processes, to ensure that it is embedded in the team’s usual business practice and is working effectively. It will be included in the induction of new staff who join the team. In regard to record keeping, the team has been reminded that in accordance with both Trust policy and professional obligations, clinical records should be full, accurate and entered in a timely manner. This will continue to be monitored through individual staff supervision and record keeping audits. If you require any further information please do not hesitate to contact me. Yours sincerely Chief Executive
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