Songul Bozdag

26 Jul 2017 · Coroner ME Hassell · London Inner (North)

The coroner's concerns

1. lack of mandatory seven day review after discharge
“Ms [name redacted] care co-ordinator did not arrange for what was a mandatory seven day review of Ms [name redacted] after discharge from hospital in August/September 2016”
2. inadequate monthly review documentation
“She recorded monthly reviews of Ms [name redacted] on only half of the months from September 2016 to Ms [name redacted] death in February 2017, though monthly reviews were mandatory”
3. unrecorded clinical interactions
“The care co-ordinator gave evidence at inquest that she had actually reviewed Ms [name redacted] once a fortnight when Ms [name redacted] came for her depot injections, but in the main did not record these discussions”
4. unsubstantiated recollection of consultations
“She described having a very good recollection of individual consultations with Ms [name redacted], such as one on 6 September 2016 though there was no record supporting this description”
5. inaccurate medication dosing documentation
“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”
6. absence of system safety net
“they were not captured by any sort of system safety net during Ms [name redacted] life”