Source · Prevention of Future Deaths
Sandra Bodrozic
Ref: 2014-0560-wp25965
Date: 24 Nov 2014
Coroner: ME Hassell
Area: London Inner (North)
Responses identified: 0 / 1
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Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack of urgency, protocol, and exploration of private bed options.
Date
24 Nov 2014
56-day deadline
19 Jan 2015 est.
Responses identified
0 of 1
Coroner's concerns
Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack of urgency, protocol, and exploration of private bed options.
View full coroner's concerns
1. Ms Bodrožic’ agreed on 23 May 2014 to the recommendation of those treating her that she be admitted to hospital on an informal basis. However, no bed was found for her until 30 May, by which time she had changed her mind.
There was no exploration of the possibility of purchasing a bed from the private sector when no NHS bed was available.
2. The consultant psychiatrist treating Ms Bodrožic’ formed the view on the evening of 18 June 2014 that Ms Bodrožic’ should have a Mental Health Act assessment. However, the psychiatrist was going on holiday the following day and so decided to leave this until her return, rather than asking colleagues.
3. The approved mental health professional (AMHP), a social worker, who visited Ms Bodrožic’ on Wednesday, 25 June 2014, decided that she needed a Mental Health Act assessment and immediately made the appropriate referral.
However, once the referral was made, it took until the following week for this to be arranged, and Ms Bodrožic’ had killed herself in the meantime, on Sunday, 29 June.
Healthcare professionals explained in court that Mental Health Act assessments are, by their very nature, urgent, yet there seemed to be a general acceptance by the team that they will usually take several days to take place, in this case from a Wednesday until the following Tuesday.
The provision for assessment is open ended, with no apparent sense of urgency, and there is no protocol for the timeframe within which this should take place, nor is a time agreed as appropriate with patient or family. Ms Bodrožic’s family were not told that, realistically, they could only obtain an immediate assessment by attending a hospital emergency unit.
There was no exploration of the possibility of purchasing a bed from the private sector when no NHS bed was available.
2. The consultant psychiatrist treating Ms Bodrožic’ formed the view on the evening of 18 June 2014 that Ms Bodrožic’ should have a Mental Health Act assessment. However, the psychiatrist was going on holiday the following day and so decided to leave this until her return, rather than asking colleagues.
3. The approved mental health professional (AMHP), a social worker, who visited Ms Bodrožic’ on Wednesday, 25 June 2014, decided that she needed a Mental Health Act assessment and immediately made the appropriate referral.
However, once the referral was made, it took until the following week for this to be arranged, and Ms Bodrožic’ had killed herself in the meantime, on Sunday, 29 June.
Healthcare professionals explained in court that Mental Health Act assessments are, by their very nature, urgent, yet there seemed to be a general acceptance by the team that they will usually take several days to take place, in this case from a Wednesday until the following Tuesday.
The provision for assessment is open ended, with no apparent sense of urgency, and there is no protocol for the timeframe within which this should take place, nor is a time agreed as appropriate with patient or family. Ms Bodrožic’s family were not told that, realistically, they could only obtain an immediate assessment by attending a hospital emergency unit.
Report sections
Investigation and inquest
On 7 July 2014, I commenced an investigation into the death of Sandra Bodrožic’, aged 39 years. The investigation concluded at the end of the inquest on 17 November 2014. I made a determination at inquest that Ms Bodrožic’ took her own life, whilst suffering a schizoaffective disorder.
Circumstances of the death
Sandra Bodrožic’ was at home with her mother when she suddenly ran up to the attic, said goodbye and jumped out of the window, landing on the ground three storeys below. Ms Bodrožic’ had been detained under the Mental Health Act on 22 October 2013 and admitted to St Pancras Hospital. She was discharged on 11 February 2014 then treated in the community until her death.
Copies sent to
Care Quality Commission for England
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Report details
- Reference
- 2014-0560-wp25965
- Date of report
- 24 November 2014
- Coroner
- ME Hassell
- Coroner area
- London Inner (North)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 19 Jan 2015 (estimated).
Sent to
- Camden & Islington NHS Foundation Trust