Naomi Suleyman
29 Jan 2025 · Coroner Liliane Field · London Inner (South)
The coroner's concerns
1. inaccurate discharge passport
“The 'discharge passport' completed by the UHL in-patient team was inaccurate, failing to record Ms [name redacted] vulnerability to pressure ulcers, the need for therapies input from day 1, the equipment she required and that her home environment had not been optimised to meet her needs both in terms of equipment and layout”
2. incorrect referral to District Nursing team
“The referral to the District Nursing team was incorrect in that it wrongly referred to Mrs [name redacted] having a sacral DTI on discharge”
3. missing welfare check
“On the day of discharge, Ms [name redacted] should have received a welfare check from the LBL out of hours social worker which did not happen”
Responses
2025-0049-Response-from-Lewisham-and-Greenwich-NHS-Trust.pdf ↗· Lewisham and Greenwich NHS Trust
Stated action · June 2025
“The nurse in charge will again review the information submitted on the discharge passport. This review will ensure that the data contained remains valid and that it is a true reflection of the patient's actual need at the proposed discharge date.”