PFD report

Sandra Bodrožič’ · Prevention of Future Deaths report

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Issued 24 Nov 2014•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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised4

  1. Failure to arrange Mental Health Act assessment when the responsible psychiatrist is unavailable
    Part of recurring concern: Failure to ensure timely and appropriate Mental Health Act assessment
  2. Failure to secure timely inpatient admission when no NHS bed is available
    Part of recurring concern: Failure to provide timely hospital admissionPart of recurring concern: Unsafe management of required admissions when no bed is available
  3. Failure to inform families of the route to obtain an immediate Mental Health Act assessment
    Part of recurring concern: Failure to provide families with information needed to support people receiving mental health care
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

    Escalate delays caused by unavailable external agencies to senior management and add recurrent delays to the Trust risk register.

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
  2. Action

    Record in the electronic patient record how risks from delays in Mental Health Act assessments will be mitigated.

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
  3. Action

    Alert commissioners to London Ambulance Service delays and poor GP attendance at Mental Health Act assessments.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 November 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Delaying the mental health assessment until the psychiatrist’s return was considered clinically reasonable because established cover arrangements were in place.

    Stated by North London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 arrange Mental Health Act assessment when the responsible psychiatrist is unavailable

Wider context from the report

“2. The consultant psychiatrist treating Ms Bodrožič’ formed the view on the evening of 18 June 2014 that Ms Bodrožič’ 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. ”

Is this part of a recurring concern?

Yes — Failure to ensure timely and appropriate Mental Health Act assessment.

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 secure timely inpatient admission when no NHS bed is available

Wider context from the report

“1. Ms Bodrožič’ 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. ”

Is this part of a recurring concern?

Yes — Failure to provide timely hospital admission; Unsafe management of required admissions when no bed is available.

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 inform families of the route to obtain an immediate Mental Health Act assessment

Wider context from the report

“3. The approved mental health professional (AMHP), a social worker, who visited Ms Bodrožič’ 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 Bodrožič’ 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 Bodrožič’s family were not told that, realistically, they could only obtain an immediate assessment by attending a hospital emergency unit. ”

Is this part of a recurring concern?

Yes — Failure to provide families with information needed to support people receiving mental health care.

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

Delays in arranging urgent Mental Health Act assessments

Wider context from the report

“3. The approved mental health professional (AMHP), a social worker, who visited Ms Bodrožič’ 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 Bodrožič’ 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 Bodrožič’s family were not told that, realistically, they could only obtain an immediate assessment by attending a hospital emergency unit. ”

Is this part of a recurring concern?

Yes — Failure to complete timely direct mental health assessments after referral; Failure to ensure timely and appropriate Mental Health Act assessment; Unreliable urgent mental health referral and assessment pathways.

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

Escalate delays caused by unavailable external agencies to senior management and add recurrent delays to the Trust risk register.

Verbatim wording from the response

“3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:”

Source location

2014-0560-Camden-Islington-NHS-Trust
Page 3 · response
Published 24 November 2014

Open published response

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

Record in the electronic patient record how risks from delays in Mental Health Act assessments will be mitigated.

Verbatim wording from the response

“3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:”

Source location

2014-0560-Camden-Islington-NHS-Trust
Page 3 · response
Published 24 November 2014

Open published response

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

Alert commissioners to London Ambulance Service delays and poor GP attendance at Mental Health Act assessments.

Verbatim wording from the response

“d) An alert to delays by the London Ambulance Service to attend MHA assessments have been made to the Joint Commissioner in Camden, and also of the poor attendance of GP’s to MHA assessments with the Joint Commissioners in the London Borough of Islington.”

Source location

2014-0560-Camden-Islington-NHS-Trust
Page 3 · response
Published 24 November 2014

Open published response

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

Clarify and disseminate the bed management policy, emphasising admission offers regardless of Mental Health Act status.

Verbatim wording from the response

“The Serious Incident Report in relation to Ms Bodrozic’s death noted that the Trust’s bed management policy was not followed correctly. Consequently, 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’. This should ensure that private beds are available to informal patients promptly.”

Source location

2014-0560-Camden-Islington-NHS-Trust
Page 2 · response
Published 24 November 2014

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Delaying the mental health assessment until the psychiatrist’s return was considered clinically reasonable because established cover arrangements were in place.

Verbatim wording from the response

“2. The Consultant Psychiatrist treating Ms Bodrozic had established a good rapport with her and her family and had made stringent efforts to engage Ms Bodrozic in her care. She felt that it was a reasonable clinical decision to carry out the MHA assessment following her period of leave. Whilst on leave, clinical cover arrangements were in place with another Consultant Psychiatrist, which is the usual procedure in order to continue to provide support to Ms Bodrozic and her family should she need arise. Ms Bodrozic brother contacted the team on 24th June expressing concerns about his sister’s mental health and following a home visit by the social worker, a referral for a MHA assessment was made.”

Source location

2014-0560-Camden-Islington-NHS-Trust
Page 3 · response
Published 24 November 2014

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

A private bed was not considered necessary because Trust bed availability was changing and a bed was expected within the required timeframe.

Verbatim wording from the response

“1. When ████████ took the decision to admit Ms Bodrozic to hospital on an informal basis on 23rd May 2014 she spoke to the duty nurse at the Highgate Mental Health Centre (the Centre) to make the referral. They discussed the urgency of the referral and although there was no bed available at the Centre it was anticipated that a bed would become available within the next few days. This was appropriate given the clinical urgency of the case at the time. Therefore, a private bed was not considered to be necessary. The family had been advised that they could take Ms Bodrozic to the Accident & Emergency department over the bank holiday weekend if there were any changes in her state of mind or behaviour.”

Source location

2014-0560-Camden-Islington-NHS-Trust
Page 2 · response
Published 24 November 2014

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

A specific agreed timeframe for mental health act assessments was not possible because coordinating multiple agencies with competing priorities can be difficult.

Verbatim wording from the response

“3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:”

Source location

2014-0560-Camden-Islington-NHS-Trust
Page 3 · response
Published 24 November 2014

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Keep families informed about likely Mental Health Act assessment timing, including attention to carers’ feelings of safety.

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.

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

Keep families informed about likely Mental Health Act assessment timing, including attention to carers’ feelings of safety.

Verbatim wording from the response

“3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:”

Source location

2014-0560-Camden-Islington-NHS-Trust
Page 3 · response
Published 24 November 2014

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