“The main issue of this inquest was to try to ascertain exactly how the wardrobe came to…”

The coroner’s concerns

– 1. The main issue of this inquest was to try to ascertain exactly how the wardrobe came to be on top of Mrs White and evidence was heard on the subject. As the evidence neared its conclusion a comment was made regarding discharge summaries and the role they play in updating risk assessments for carers. 2. I am fully aware that the hospital did not have the opportunity to put forward any information on this point, however it is my statutory duty to make a report to prevent future death, and the evidence in this case was that this was an issue that occurred regularly. 3. Prior to this incident occurring Mrs White had been in hospital and discharged on 4th October 2023. A manager for the care home outlined that the paperwork provided to carers known as the “Discharge Summary” is often inadequate in providing suitable information. In this instance I was informed it did not provide any information on Mrs White’s increased frailty and decreased mobility. This means that information provided is inappropriate for ongoing risk assessments. 4. The manager did outline a particular form that they prefer, I make no comment regarding the format of the information required, merely the need for appropriate information to allow risk assessments to take place. 5. The manager stated that a social worker should be completing a risk assessment prior to discharge but this often does not happen. In many cases a doctor or another member of staff will complete a discharge summary. The information in these is often lacking to safeguard the welfare of the person concern with regard to their care needs. The manager stated they often have to alert safeguarding at the local authority of the deficit. 6. Bearing in mind the importance of a discharge summary in providing the foundation information for the ongoing safe care of patients as they leave the hospital environment, this is an issue where either a structured approach is required or training to those who are failing to complete them correctly is required. 3

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, 2024-0044

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0