“Since 2020 Ms Levy had been provided with domiciliary care commissioned by the local…”
Dated 31 Aug 2023, from the coroner for East London. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 26 Oct 2023. A reply may have been sent and not yet published.
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.
- Report dated31 Aug 2023
- Deadline26 Oct 2023
- Published on judiciary.uk8 Sep 2023
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North East London NHS Foundation TrustNamed in the report as “North East London Foundation Trust” | Response publishedPublished on judiciary.uk in September 2023. |
| London Borough of Redbridge Council | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 26 Oct 2023. A reply may have been sent and not yet published. |
| Department of Health and Social CareNamed in the report as “Department for Health and Social Care” | Response publishedPublished on judiciary.uk in September 2023. |
The coroner’s concerns
1. Since 2020 Ms Levy had been provided with domiciliary care commissioned by the local authority. At the time of her death twice daily visits were undertaken. Ms Levy was utilising state funded domiciliary care visits to deliver fast food to her home, no personal care was being provided. Carers had escalated to the local authority Ms Levy's reluctance to accept personal care and raised safeguarding reports regarding Ms Levy's living conditions. 2. In the two months prior to her final admission into hospital Ms Levy was being regularly assessed by district nurses, the community matron and her GP. Despite the obvious nature of her deteriorating health, no meaningful steps were taken to escalate the care she received to mitigate the risks of her self-neglect. 3. The inquest heard that as Ms Levy was believed to have capacity throughout this period, and consequently it was determined that there were on practical steps that could have been taken to improve the provision of care to her. 4. No formal Mental Capacity Act assessment was ever undertaken or considered. 2 6 5. No formal referral was made to mental health services regarding Ms Levy's reluctance to take advantage of offered care. 6. The Trust responsible for community care did not undertake a Serious Investigation. The decision was justified on the basis that Ms Levy's pressure sore was insufficiently significant to justify further inquiry. The decision was, in the view of the court flawed as evidence heard indicated that the pressure sore was in fact far more serious than appreciated at the time of community treatment. Further, restricting the scope of a serious incident report to the extent of a single pressure sore, neglected to take in the wider physical health problems suffered by Ms Levy that were obvious at that time.
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, 2023-0315
- 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
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