“Evidence was heard that: (1) A recommended home assessment was not completed as part of…”

The coroner’s concerns

– Evidence was heard that: (1) A recommended home assessment was not completed as part of Mr Smith’s planned discharge from hospital. (2) The next of kin was incorrectly recorded on Mr Smith’s medical records and the family were not informed of his discharge home as part of the discharge planning that he required care. (3) Mr Smith remained on a discharge ward from 2nd February until his discharge on 10th February even though he suffered a deterioration in his medical condition. Mr Smith’s capacity fluctuated during his admission, he was noted by nurses to be confused and his capacity was not reassessed. (4) Nursing notes in respect of Mr Smith’s discharge were incomplete, incorrect, and led to assumptions being made that Mr Smith a. had capacity to make decisions about his care and treatment b. was being cared for in the community. (5) Mr Smith has extensive leg ulcers that required specialist input. No district nurse referral was made to ensure that Mr Smith’s leg ulcers were treated. (6) Transport staff returning Mr Smith home found he had no key. One was located and on entering the property found conditions that caused them serious concern about the hygiene and health and safety within the property with a leak, uncleanliness and exposed electrical wiring and that there was no bed. (7) Transport staff were informed by the hospital not to return Mr Smith to the hospital as there was no bed available and they therefore raised a safeguarding alert. The safeguarding alert was not acted upon and Mr Smith was found by family after five days lying on the floor of his home with no dressing on his legs, unable to move and with no access to food or drink. (8) On readmission to hospital his dietary requirements were not adequate for his needs.

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, 2021-0025

Added to Minute Book

8 Oct 2026

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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