“In respect of the D2A service (LGT and LBL): (1) The ‘discharge passport’ completed by…”

The coroner’s concerns

– In respect of the D2A service (LGT and LBL): (1) The ‘discharge passport’ completed by the UHL in-patient team was inaccurate, failing to record Ms Suleyman’s 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. Whilst I heard that scrutiny of the discharge passport had improved at ward level, deficient discharge passports were still filtering through to the D2A team. (2) The deficiencies in the discharge passport were not identified when it was screened by the LGT Hospital Flow Centre. (3) On the day of discharge, Ms Suleyman should have received a welfare check from the LBL out of hours social worker which did not happen. (4) Due to lack of capacity, Ms Suleyman’s interim care needs pending assessment were brokered to a care provider. As a result, she did not receive a visit from a social worker and/or occupational therapist within 24 hours of discharge as she would have done if her care needs had been provided by the in-house Enablement team. In respect of the involvement of the District Nursing Service (LGT) (1) The referral to the District Nursing team was incorrect in that it wrongly referred to Mrs Suleyman having a sacral DTI on discharge. This led the District Nursing team to believe that she was already on the caseload of the community TVN team. This resulted in a delay in her being assessed by them. (2) There was little communication between the therapists from the D2A team and the District Nurses. As a consequence of these deficiencies there were missed opportunities to recognise that Ms Suleyman’s discharge was unsafe and act upon that. The issues relating to LBL only emerged in evidence during the inquest. LGT in-patient and District Nursing services have taken some steps towards addressing their deficiencies. However, there has been a fragmented and incomplete response. There has been no overarching coordinated investigation involving all the key services relevant to what is intended to be an integrated multi-disciplinary discharge process.

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, 2025-0049

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