“The Tissue Viability Nurse and District Nurses are a part of the same community team but…”
Dated 21 Feb 2020, from the coroner for South London. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 17 Apr 2020.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated21 Feb 2020
- Deadline17 Apr 2020
- Published on judiciary.uk27 Mar 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Central London Community Healthcare NHS Trust | Response publishedPublished on judiciary.uk in June 2022. |
The coroner’s concerns
(1) The Tissue Viability Nurse and District Nurses are a part of the same community team but no steps had been taken to attend to the management of Anita Loi’s leg wound despite repeated referrals by the GP and a call to the community team by the family. (2) On 11 December 2019 the GP invited the District Nurses Team and Tissue Viability Nurses Team to attend a meeting at the surgery with the practice clinicians to review unexpected deaths and to discuss this case. Neither team attended the meeting and to date have not engaged with the GP in relation to this death despite a chasing letter. (3) whether there are appropriate policies, procedures protocols in place for the referral of patients to the service, and the response to such referrals
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2020-0067
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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