Demet Akcicek
PFD Report
All Responded
Ref: 2022-0277
All 1 response received
· Deadline: 30 Nov 2022
Response Status
Responses
1 of 1
56-Day Deadline
30 Nov 2022
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
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.
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.
Responses
The Trust has updated its CDAT Operational Policy and implemented a daily duty sheet/tracker, which officially started on 24th October, to ensure appropriate follow-up for all logged issues. Staff have also been reminded of professional obligations for full and accurate record-keeping.
AI summary
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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.
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
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.
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
Report Sections
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.
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.
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.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.