PFD report

Demet AKCICEK · Prevention of Future Deaths report

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Issued 7 Sep 2022•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to identify patients requiring service review for multidisciplinary discussion and follow-up
    Part of recurring concern: Failure of case monitoring to identify cases requiring follow-upPart of recurring concern: Failure to provide timely continuing mental health reviews and follow-up
  2. Failure to produce clear and sufficient clinical notes
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  3. Failure to implement steps to prevent recurrence of documentation and follow-up errors
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Include the new duty-tracking process in induction for new CDAT staff.

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 October 2022.
  2. Action

    Remind staff of clinical record-keeping requirements and monitor compliance through supervision and record-keeping audits.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
  3. Action

    Review and monitor the new duty-tracking process through scheduled review, audit and governance processes to ensure effective embedding.

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 October 2022.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to identify patients requiring service review for multidisciplinary discussion and follow-up

Wider context from the report

“When the duty worker from Islington complex depression, anxiety and trauma (CDAT) service rang Ms Akcicek for a welfare check on 25 November 2021, Ms Akcicek reported feeling “quite bad” and that she wanted to cry. She explained that she had difficulty performing everyday activities such as cooking and taking her child to school. She said that two nights earlier, her son reported that she had woken chanting, “I don’t want to die, I don’t want to die”. The duty worker (a registered mental health nurse) formed the view that Ms Akcicek needed to be seen by the service, but failed to put her name on the board, and so she was not discussed at the multi disciplinary team meeting and no follow up was arranged. In addition, the duty worker accepted in court that her note of the conversation was insufficient. I found the note difficult to understand and the duty worker was not able fully to explain its meaning. The duty worker told me that she will not make such mistakes again. However, I did not hear evidence of what steps, if any, Camden & Islington Trust has taken to avoid such a situation arising in future. ”

Is this part of a recurring concern?

Yes — Failure of case monitoring to identify cases requiring follow-up; Failure to provide timely continuing mental health reviews and follow-up.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to produce clear and sufficient clinical notes

Wider context from the report

“When the duty worker from Islington complex depression, anxiety and trauma (CDAT) service rang Ms Akcicek for a welfare check on 25 November 2021, Ms Akcicek reported feeling “quite bad” and that she wanted to cry. She explained that she had difficulty performing everyday activities such as cooking and taking her child to school. She said that two nights earlier, her son reported that she had woken chanting, “I don’t want to die, I don’t want to die”. The duty worker (a registered mental health nurse) formed the view that Ms Akcicek needed to be seen by the service, but failed to put her name on the board, and so she was not discussed at the multi disciplinary team meeting and no follow up was arranged. In addition, the duty worker accepted in court that her note of the conversation was insufficient. I found the note difficult to understand and the duty worker was not able fully to explain its meaning. The duty worker told me that she will not make such mistakes again. However, I did not hear evidence of what steps, if any, Camden & Islington Trust has taken to avoid such a situation arising in future. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to implement steps to prevent recurrence of documentation and follow-up errors

Wider context from the report

“When the duty worker from Islington complex depression, anxiety and trauma (CDAT) service rang Ms Akcicek for a welfare check on 25 November 2021, Ms Akcicek reported feeling “quite bad” and that she wanted to cry. She explained that she had difficulty performing everyday activities such as cooking and taking her child to school. She said that two nights earlier, her son reported that she had woken chanting, “I don’t want to die, I don’t want to die”. The duty worker (a registered mental health nurse) formed the view that Ms Akcicek needed to be seen by the service, but failed to put her name on the board, and so she was not discussed at the multi disciplinary team meeting and no follow up was arranged. In addition, the duty worker accepted in court that her note of the conversation was insufficient. I found the note difficult to understand and the duty worker was not able fully to explain its meaning. The duty worker told me that she will not make such mistakes again. However, I did not hear evidence of what steps, if any, Camden & Islington Trust has taken to avoid such a situation arising in future. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Include the new duty-tracking process in induction for new CDAT staff.

Verbatim wording from the 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.”

Source location

Response from Camden and Islington NHS Foundation Trust
Page 1 · response
Published 5 October 2022

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Remind staff of clinical record-keeping requirements and monitor compliance through supervision and record-keeping audits.

Verbatim wording from the response

“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.”

Source location

Response from Camden and Islington NHS Foundation Trust
Page 1 · response
Published 5 October 2022

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review and monitor the new duty-tracking process through scheduled review, audit and governance processes to ensure effective embedding.

Verbatim wording from the 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.”

Source location

Response from Camden and Islington NHS Foundation Trust
Page 1 · response
Published 5 October 2022

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement the updated CDAT operational policy and daily duty tracker, with same-day logging and senior daily cross-checks for follow-up.

Verbatim wording from the response

“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.”

Source location

Response from Camden and Islington NHS Foundation Trust
Page 1 · response
Published 5 October 2022

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026