Songul Bozdag
PFD Report
All Responded
Ref: 2017-0219
All 1 response received
· Deadline: 20 Nov 2017
Coroner's Concerns (AI summary)
The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to under-medication, with no systemic safety net.
View full coroner's concerns
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. 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.
Responses
Action Taken
The Trust has implemented an inbox-based system to communicate discharge care plans to CMHT staff, and monthly supervision for care coordinators is now working in line with Trust procedures. Regular audits are being undertaken to maintain a robust oversight on the process. (AI summary)
The Trust has implemented an inbox-based system to communicate discharge care plans to CMHT staff, and monthly supervision for care coordinators is now working in line with Trust procedures. Regular audits are being undertaken to maintain a robust oversight on the process. (AI summary)
View full response
Dear Madam Inquest touching upon the death of Songul Bozdag This is a formal response to your Regulation 28 Report dated 8th August in which you set out your concerns 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 t0 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: Chief Executive: Dr Navina Evans relating
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 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 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 have been followed up. This include seven day follow upS, medical reviews and changes in medication: This new process will also allow senior practitioners to allocate actions to a worker if the care coordinator is absent from work or unable to undertake an intervention for any reason: The 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.
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 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 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 have been followed up. This include seven day follow upS, medical reviews and changes in medication: This new process will also allow senior practitioners to allocate actions to a worker if the care coordinator is absent from work or unable to undertake an intervention for any reason: The 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.
Sent To
- East London NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
20 Nov 2017
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
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.
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.
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. 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.
Copies Sent To
, consultant psychiatrist
care co
ordinator
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.