Mohammed Akram
PFD Report
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Ref: 2023-0474
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· Deadline: 22 Jan 2024
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
I heard evidence that there was no routine mechanism to cross reference what people are prescribed and what medication they are actually collecting, and no automatic notification to GPs who are responsible for the medication prescribing. Zee informed BEH that he had not taken his olanzapine and fluoxetine for two weeks. His GP, who was prescribing that medication, was not informed.
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Dear Madam,
Regarding: Mr Mohammed Zeeshan Akram (Zee) DOB: 22/11/90
Date of death: 21/03/2023 Address: Known to the Trust
This letter forms the Barnet Enfield and Haringey Mental Health NHS Trust’s (“the Trust”) response to the application sections of the Prevention of Future Deaths Report following the hearing regarding the death of Mr Mohammed Zeeshan Akram (Zee), held on 6th September 2023 before Assistant Coroner Lee at St Pancras Coroner’s Court.
The MATTERS OF CONCERN are as follows.
I heard evidence that there was no routine mechanism to cross reference what people are prescribed and what medication they are actually collecting, and no automatic notification to GPs who are responsible for the medication prescribing. Zee informed BEH that he had not taken his olanzapine and fluoxetine for two weeks. His GP, who was prescribing that medication, was not informed.
I am concerned that GPs are not updated, particularly where patients have expressed suicidal ideation, and may not be aware that people are not taking medication and/or that there may be a risk of stockpiling.
The above matters were considered, and the following response is provided.
The usual procedure within the Early Intervention Psychosis Service (“the service”) when the clinical team become aware that a client is not taking their medication as prescribed, is to discuss this with the client, their family, and carers (where appropriate) to understand the reasons behind this and to support the client to continue with the medication as prescribed wherever possible.
Private & Confidential
For the attention of: His Majesty’s Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP
Senior Service Lead Haringey Community Mental Health Services Barnet, Enfield and Haringey Mental Health NHS Trust St. Ann’s Hospital St. Ann’s Road Tottenham London N15 3TH
In situations where the client is experiencing side-effects, has stopped their medication completely or is requesting a change in medication, a review with the prescribing clinician will be arranged. The timeframe for this review will be informed by the urgency of the issue and associated risks. In the service, one in three of the medical appointments are always available for urgent reviews within five working days.
This medication review by the prescribing clinician will automatically lead to the GP being notified when there are any changes to the client’s prescription or treatment plan, including whether the client has stopped taking the medication and any steps the service is taking to provide additional support. The expected standard is the GP would receive this correspondence via email within 48 hours of the medical review. In cases where a rapid medical review is arranged, the service will usually wait until the review before updating the GP, to ensure the GP is provided with the most up to date treatment plan.
Where there are concerns about a use of specific medication, e.g., benzodiapenes or Lithium, clinicians will routinely liaise with GPs to ensure safe prescribing, outside of planned medical reviews.
In this case, the clinician became aware the client had stopped taking his prescribed medication on Thursday 16th March 2023, which led to a multidisciplinary team (MDT) discussion at which the agreed plan was for an urgent medical review. This was arranged for Monday 20th March 2023,the next available urgent appointment. The MDT discussion also considered whether a referral to a Crisis Resolution & Home Treatment Team was warranted, but felt the threshold was not met.
Since the medical review was arranged for two working days after the service was made aware the client had stopped their medication, we would not have expected additional communication with the GP prior to the medical review.
The Trust is grateful for the opportunity to review procedures following Mr Akram’s passing.
Finally, the Trust offers its sincere condolences to the family and friends of Mr Akram. In doing so, the Trust remains committed to the delivery of patient-centred care to its service users.
We hope the above has addressed the matters raised in the Prevention of Future Deaths report.
Regarding: Mr Mohammed Zeeshan Akram (Zee) DOB: 22/11/90
Date of death: 21/03/2023 Address: Known to the Trust
This letter forms the Barnet Enfield and Haringey Mental Health NHS Trust’s (“the Trust”) response to the application sections of the Prevention of Future Deaths Report following the hearing regarding the death of Mr Mohammed Zeeshan Akram (Zee), held on 6th September 2023 before Assistant Coroner Lee at St Pancras Coroner’s Court.
The MATTERS OF CONCERN are as follows.
I heard evidence that there was no routine mechanism to cross reference what people are prescribed and what medication they are actually collecting, and no automatic notification to GPs who are responsible for the medication prescribing. Zee informed BEH that he had not taken his olanzapine and fluoxetine for two weeks. His GP, who was prescribing that medication, was not informed.
I am concerned that GPs are not updated, particularly where patients have expressed suicidal ideation, and may not be aware that people are not taking medication and/or that there may be a risk of stockpiling.
The above matters were considered, and the following response is provided.
The usual procedure within the Early Intervention Psychosis Service (“the service”) when the clinical team become aware that a client is not taking their medication as prescribed, is to discuss this with the client, their family, and carers (where appropriate) to understand the reasons behind this and to support the client to continue with the medication as prescribed wherever possible.
Private & Confidential
For the attention of: His Majesty’s Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP
Senior Service Lead Haringey Community Mental Health Services Barnet, Enfield and Haringey Mental Health NHS Trust St. Ann’s Hospital St. Ann’s Road Tottenham London N15 3TH
In situations where the client is experiencing side-effects, has stopped their medication completely or is requesting a change in medication, a review with the prescribing clinician will be arranged. The timeframe for this review will be informed by the urgency of the issue and associated risks. In the service, one in three of the medical appointments are always available for urgent reviews within five working days.
This medication review by the prescribing clinician will automatically lead to the GP being notified when there are any changes to the client’s prescription or treatment plan, including whether the client has stopped taking the medication and any steps the service is taking to provide additional support. The expected standard is the GP would receive this correspondence via email within 48 hours of the medical review. In cases where a rapid medical review is arranged, the service will usually wait until the review before updating the GP, to ensure the GP is provided with the most up to date treatment plan.
Where there are concerns about a use of specific medication, e.g., benzodiapenes or Lithium, clinicians will routinely liaise with GPs to ensure safe prescribing, outside of planned medical reviews.
In this case, the clinician became aware the client had stopped taking his prescribed medication on Thursday 16th March 2023, which led to a multidisciplinary team (MDT) discussion at which the agreed plan was for an urgent medical review. This was arranged for Monday 20th March 2023,the next available urgent appointment. The MDT discussion also considered whether a referral to a Crisis Resolution & Home Treatment Team was warranted, but felt the threshold was not met.
Since the medical review was arranged for two working days after the service was made aware the client had stopped their medication, we would not have expected additional communication with the GP prior to the medical review.
The Trust is grateful for the opportunity to review procedures following Mr Akram’s passing.
Finally, the Trust offers its sincere condolences to the family and friends of Mr Akram. In doing so, the Trust remains committed to the delivery of patient-centred care to its service users.
We hope the above has addressed the matters raised in the Prevention of Future Deaths report.
Report Sections
Investigation and Inquest
On 27 March 2023 an investigation was commenced into the death of Mohammed Zeeshan Akram, date of birth 22 November 1993. The investigation concluded at the end of the inquest on 6 September 2023. The conclusion was suicide. The medical cause of death was 1a. multiorgan failure; 1b. acute ethylene glycol toxicity; 2. mental health disorder.
Circumstances of the Death
Zee had a history of suicidal ideation and reported suicide attempts dating back to his childhood. In February 2019 he was diagnosed with a psychotic disorder. He received support for his mental health from the Crisis Team in 2019 and spent two days as a mental health inpatient.
In December 2022 Zee reported panic attacks and auditory hallucinations. He was taken on by the Crisis Team who prescribed diazepam, zopiclone, olanzapine and fluoxetine. On 30 December there was a joint review by the Home Treatment Team and Haringey (BEH) Early Intervention Service (EIS) at St Ann’s Hospital and Zee was allocated a care coordinator. On 30 December Zee was discharged from the Home Treatment Team who wrote asking the GP to continue repeating his medications which were zopiclone olanzapine , fluoxetine and diazepam .
In February 2023 Zee’s mental health deteriorated. On 15 February he reported EIS that he was experiencing negative side effects from his medication but that he felt mostly optimistic. He requested a reduction of olanzapine.
There was an exchange of text messages between Zee and a dual diagnosis recovery worker between 17 February and 15 March in which Zee appeared upbeat, said that he was attending work and gave no cause for the recovery worker to be concerned.
On 16 March Zee attended an appointment and informed his recovery worker that he had stopped taking his olanzapine and fluoxetine 2 weeks previously due to numbness that had led to suicidal ideation. The recovery worker went out of his way to arrange an urgent medical review for Monday 20 March. Zee was given safety netting advice.
After this appointment, Zee went to where he spent several hours contemplating throwing himself into the Thames. He did not inform his recovery worker of this or contact the crisis team.
On Friday 17 March the recovery worker sent Zee a text message with the appointment for a medical review on Monday 20 March. Zee replied that he was unable to make the appointment as he was working on the Monday and so the appointment was rearranged for Tuesday 21 March.
On 20 March Zee did not attend work. A friend went to his flat and found Zee unresponsive. Zee was taken to the Whittington Hospital where he died on 21 March 2023.
In December 2022 Zee reported panic attacks and auditory hallucinations. He was taken on by the Crisis Team who prescribed diazepam, zopiclone, olanzapine and fluoxetine. On 30 December there was a joint review by the Home Treatment Team and Haringey (BEH) Early Intervention Service (EIS) at St Ann’s Hospital and Zee was allocated a care coordinator. On 30 December Zee was discharged from the Home Treatment Team who wrote asking the GP to continue repeating his medications which were zopiclone olanzapine , fluoxetine and diazepam .
In February 2023 Zee’s mental health deteriorated. On 15 February he reported EIS that he was experiencing negative side effects from his medication but that he felt mostly optimistic. He requested a reduction of olanzapine.
There was an exchange of text messages between Zee and a dual diagnosis recovery worker between 17 February and 15 March in which Zee appeared upbeat, said that he was attending work and gave no cause for the recovery worker to be concerned.
On 16 March Zee attended an appointment and informed his recovery worker that he had stopped taking his olanzapine and fluoxetine 2 weeks previously due to numbness that had led to suicidal ideation. The recovery worker went out of his way to arrange an urgent medical review for Monday 20 March. Zee was given safety netting advice.
After this appointment, Zee went to where he spent several hours contemplating throwing himself into the Thames. He did not inform his recovery worker of this or contact the crisis team.
On Friday 17 March the recovery worker sent Zee a text message with the appointment for a medical review on Monday 20 March. Zee replied that he was unable to make the appointment as he was working on the Monday and so the appointment was rearranged for Tuesday 21 March.
On 20 March Zee did not attend work. A friend went to his flat and found Zee unresponsive. Zee was taken to the Whittington Hospital where he died on 21 March 2023.
Copies Sent To
(Zee’s friend)
(Zee’s GP)
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.