Sandra Bodrozic
24 Nov 2014 · Coroner ME Hassell · London Inner (North)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of available NHS bed
“no bed was found for her until 30 May, by which time she had changed her mind”
2. delay in initiating Mental Health Act assessment
“the psychiatrist was going on holiday the following day and so decided to leave this until her return, rather than asking colleagues”
3. delayed referral processing
“it took until the following week for this to be arranged, and Ms Bodrožic' had killed herself in the meantime”
4. lack of urgency in assessment scheduling
“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”
5. inadequate follow‑up after referral
“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.”
6. lack of information to family about assessment access
“Ms Bodrožic's family were not told that, realistically, they could only obtain an immediate assessment by attending a hospital emergency unit”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“there seemed to be a general acceptance by the team that they will usually take several days to take place”
Later report
“In evidence the community recovery team indicated that a factor in their inaction was the knowledge that arranging a section 135 mental health act 1983 warrant and assessment would take two weeks.”
Responses
2014-0560-Camden-Islington-NHS-Trust.pdf ↗· Camden and Islington NHS Foundation Trust
Stated action
“the Clinical Director for the Acute Division has clarified and disseminate the Trust's bed management policy to its employees emphasising that, 'any patient requiring a bed will be offered admission regardless of their Mental Health Act status'”