Camden and Islington NHS Foundation Trust
NHS / Health Body
Action Taken
The CDAT team has updated its Operational Policy and implemented a daily duty sheet/tracker to ensure appropriate follow-up for all issues logged, which is checked daily by the senior on duty. The team has also been reminded of record-keeping obligations. (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