Naomi Suleyman
PFD Report
Partially Responded
Ref: 2025-0049
Coroner's Concerns (AI summary)
Inaccurate discharge passports, inadequate screening, missed welfare checks, and delayed community care referrals led to an unsafe patient discharge, compounded by fragmented service responses.
View full 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.
(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.
Responses
Action Taken
Lewisham and Greenwich NHS Trust has implemented measures to improve discharge passports, including input from all ward-based team members and mandatory review by a senior therapist. They have also established pathways for escalating concerns between community services and regular meetings between the Discharge to Assess team and District Nurses, with a communication champion overseeing the process. (AI summary)
Lewisham and Greenwich NHS Trust has implemented measures to improve discharge passports, including input from all ward-based team members and mandatory review by a senior therapist. They have also established pathways for escalating concerns between community services and regular meetings between the Discharge to Assess team and District Nurses, with a communication champion overseeing the process. (AI summary)
View full response
Dear Ms Field
RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Re: Ms Naomi Suleyman
Dear Ms Field
We are writing in response to your prevention of future death report dated 29th January 2025, concerning the care provided to Ms Naomi Suleyman.
Your report highlighted in total six matters of concern.
In respect of the D2A service which is an integrated multidisciplinary team of Health and Social Care professionals employed by both (Lewisham and Greenwich NHS Trust (LGT) and London Borough of Lewisham (LBL), the Coroner raised four concerns.
All four of these concerns have been considered both jointly and separately by the D2A service, Concern 1-2 is responded to by LGT, and concern 3-4 is a joint response by LGT and LBL.
The coroner raised 2 further concerns relating to the district nursing team only which has also been addressed in this response by LGT.
• Concern 1 (response from LGT)
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
• Each member of the ward-based team, who is involved in the patient care, now provides input into the centrally located (and saved) discharge passports.
• The nurse in charge of the shift holds overall responsibility for checking the information contained, prior to sending the document to the hospital discharge teams.
• Once checked and approved, the hospital discharge team will ensure the passports are uploaded to the electronic patient record
• The confirmed discharge plan and date is confirmed daily multidisciplinary ward review meetings which comprise of the lead Doctor and Nurse, therapists, relevant nurse specialists, pharmacist and other specialists where appropriate. The discharge plan is then updated in the electronic patient record. A new electronic bed management system will be going live in the trust in June 2025, which will facilitate the sharing of information regarding the planned discharge date.
• The nurse in charge will again review the information submitted on the discharge passport. This review will ensure that the data contained remains valid and that it is a true reflection of the patient's actual need at the proposed discharge date.
• A multidisciplinary task and finish group has commenced work to outline standards of practice, and to define roles and responsibilities relating to prescription of pressure care equipment and hospital beds. The project will be undertaken using Quality improvement methodology and will produce guidance materials and teaching for staff by end of April 2025.
• A multi-agency discharge event was carried out on 05/03/2025 which tests the systematic approach to discharge processes and further events are planned to improve multi agency communication and ways of working.
• An Occupational Therapy Policy has been developed which outlines roles, responsibilities and processes relating to therapy practice for environmental assessments and equipment provision. This is currently being agreed through the Trusts governance procedures.
Concern 2 (response from LGT)
• The deficiencies in the discharge passport were not identified when it was screened by the LGT Hospital Flow Centre.
• The discharge team now perform additional checks on the patient electronic care record to ensure there have been no last-minute changes in the patient's condition or discharge support needs. This is underpinned by a new protocol which has been shared with the team and operationally embedded into working practices.
Concern 3 and 4 - Joint response from LGT and LBL
• 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. Due to lack of capacity, Ms Suleyman’s interim care needs pending assessment were brokered to a care
3
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.
• Any client in receipt of Enablement or brokered out care provision now receives a visit from an Enablement Care Officer, this visit happens the same day that the patient is discharged from hospital and reviews the suitability of care provision once the patient is in their own environment. Any changes are fed back to the Discharge to Assess Team (occupational therapist, physiotherapist or social worker) and patient, carer or other family members.
• For those patients discharged out of hours between 5pm-8pm) the out of hours social worker ensures that a welfare call is carried out the next day.by a therapist and/or social worker
• There is now an established pathway, for escalation of concerns and information sharing between community services (Podiatry, District nursing and Community therapies/Enablement). This information has been shared across the services and embedded at all levels and will be monitored and audited moving forward.
• Escalation processes between care agencies and community services has been established for some time. This has also been reshared with community care providers.
• Escalation processes for GP services are well established and in good use.
• Community leads across therapies, district nursing, podiatry and enablement services; have systems in place to action urgent reviews by the most appropriate person, should it be required.
In respect of the involvement of the District Nursing Service (LGT)
Concern 1
• The referral to the District Nursing team was incorrect in that it wrongly referred to Ms 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.
• On further investigation the District Nursing referral was done in a timely way from the ward on the day of discharge and received and actioned by the DN team. The referral noted both the foot ulcers and the sacral ulcer correctly.
• In order to ensure that the DN team identify complex wounds in future and refer to the TVN, a new process has been implemented during the first assessment, if there is any uncertainty about TVN involvement in complex wounds, the DN team will confirm this directly and ensure a referral is made if required
Concern 2
• There was little communication between the therapists from the D2A team and the District Nurses.
4
• An established pathway for the escalation of urgent concerns between community services (Podiatry, District Nursing, and Community Therapies/Enablement) is in place. All staff have been reminded of the process.
• Additionally, training sessions will be initiated for community therapy services and district nurses and delivered between April and June 2025 to enhance awareness of available services and referral procedures.
• In response to the report highlighting limited communication between the Discharge to Assess team and District Nurses, regular meetings have already been established between the teams to ensure consistent exchange of patient information. A staff member, or communication champion, has been appointed to oversee this process and ensure that care plans are followed. These communication efforts are being actively monitored and evaluated to confirm their effectiveness in preventing any future issues.
In conclusion ensuring compliance and the effectiveness of new processes will be overseen and monitored in a joint Lewisham and Greenwich NHS Trust (LGT) and London Borough of Lewisham (LBL) oversight meeting. This group will meet monthly and commences in April 2025.
I would like to assure you that Lewisham and Greenwich NHS Trust and London Borough of Lewisham have taken the concerns raised seriously and learning from this incident will be shared and overseen by the Divisional Governance Meeting.
Should you have any further questions regarding any of the information provided in this letter or require any further information please do not hesitate to contact us.
RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Re: Ms Naomi Suleyman
Dear Ms Field
We are writing in response to your prevention of future death report dated 29th January 2025, concerning the care provided to Ms Naomi Suleyman.
Your report highlighted in total six matters of concern.
In respect of the D2A service which is an integrated multidisciplinary team of Health and Social Care professionals employed by both (Lewisham and Greenwich NHS Trust (LGT) and London Borough of Lewisham (LBL), the Coroner raised four concerns.
All four of these concerns have been considered both jointly and separately by the D2A service, Concern 1-2 is responded to by LGT, and concern 3-4 is a joint response by LGT and LBL.
The coroner raised 2 further concerns relating to the district nursing team only which has also been addressed in this response by LGT.
• Concern 1 (response from LGT)
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
• Each member of the ward-based team, who is involved in the patient care, now provides input into the centrally located (and saved) discharge passports.
• The nurse in charge of the shift holds overall responsibility for checking the information contained, prior to sending the document to the hospital discharge teams.
• Once checked and approved, the hospital discharge team will ensure the passports are uploaded to the electronic patient record
• The confirmed discharge plan and date is confirmed daily multidisciplinary ward review meetings which comprise of the lead Doctor and Nurse, therapists, relevant nurse specialists, pharmacist and other specialists where appropriate. The discharge plan is then updated in the electronic patient record. A new electronic bed management system will be going live in the trust in June 2025, which will facilitate the sharing of information regarding the planned discharge date.
• The nurse in charge will again review the information submitted on the discharge passport. This review will ensure that the data contained remains valid and that it is a true reflection of the patient's actual need at the proposed discharge date.
• A multidisciplinary task and finish group has commenced work to outline standards of practice, and to define roles and responsibilities relating to prescription of pressure care equipment and hospital beds. The project will be undertaken using Quality improvement methodology and will produce guidance materials and teaching for staff by end of April 2025.
• A multi-agency discharge event was carried out on 05/03/2025 which tests the systematic approach to discharge processes and further events are planned to improve multi agency communication and ways of working.
• An Occupational Therapy Policy has been developed which outlines roles, responsibilities and processes relating to therapy practice for environmental assessments and equipment provision. This is currently being agreed through the Trusts governance procedures.
Concern 2 (response from LGT)
• The deficiencies in the discharge passport were not identified when it was screened by the LGT Hospital Flow Centre.
• The discharge team now perform additional checks on the patient electronic care record to ensure there have been no last-minute changes in the patient's condition or discharge support needs. This is underpinned by a new protocol which has been shared with the team and operationally embedded into working practices.
Concern 3 and 4 - Joint response from LGT and LBL
• 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. Due to lack of capacity, Ms Suleyman’s interim care needs pending assessment were brokered to a care
3
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.
• Any client in receipt of Enablement or brokered out care provision now receives a visit from an Enablement Care Officer, this visit happens the same day that the patient is discharged from hospital and reviews the suitability of care provision once the patient is in their own environment. Any changes are fed back to the Discharge to Assess Team (occupational therapist, physiotherapist or social worker) and patient, carer or other family members.
• For those patients discharged out of hours between 5pm-8pm) the out of hours social worker ensures that a welfare call is carried out the next day.by a therapist and/or social worker
• There is now an established pathway, for escalation of concerns and information sharing between community services (Podiatry, District nursing and Community therapies/Enablement). This information has been shared across the services and embedded at all levels and will be monitored and audited moving forward.
• Escalation processes between care agencies and community services has been established for some time. This has also been reshared with community care providers.
• Escalation processes for GP services are well established and in good use.
• Community leads across therapies, district nursing, podiatry and enablement services; have systems in place to action urgent reviews by the most appropriate person, should it be required.
In respect of the involvement of the District Nursing Service (LGT)
Concern 1
• The referral to the District Nursing team was incorrect in that it wrongly referred to Ms 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.
• On further investigation the District Nursing referral was done in a timely way from the ward on the day of discharge and received and actioned by the DN team. The referral noted both the foot ulcers and the sacral ulcer correctly.
• In order to ensure that the DN team identify complex wounds in future and refer to the TVN, a new process has been implemented during the first assessment, if there is any uncertainty about TVN involvement in complex wounds, the DN team will confirm this directly and ensure a referral is made if required
Concern 2
• There was little communication between the therapists from the D2A team and the District Nurses.
4
• An established pathway for the escalation of urgent concerns between community services (Podiatry, District Nursing, and Community Therapies/Enablement) is in place. All staff have been reminded of the process.
• Additionally, training sessions will be initiated for community therapy services and district nurses and delivered between April and June 2025 to enhance awareness of available services and referral procedures.
• In response to the report highlighting limited communication between the Discharge to Assess team and District Nurses, regular meetings have already been established between the teams to ensure consistent exchange of patient information. A staff member, or communication champion, has been appointed to oversee this process and ensure that care plans are followed. These communication efforts are being actively monitored and evaluated to confirm their effectiveness in preventing any future issues.
In conclusion ensuring compliance and the effectiveness of new processes will be overseen and monitored in a joint Lewisham and Greenwich NHS Trust (LGT) and London Borough of Lewisham (LBL) oversight meeting. This group will meet monthly and commences in April 2025.
I would like to assure you that Lewisham and Greenwich NHS Trust and London Borough of Lewisham have taken the concerns raised seriously and learning from this incident will be shared and overseen by the Divisional Governance Meeting.
Should you have any further questions regarding any of the information provided in this letter or require any further information please do not hesitate to contact us.
Sent To
- Lewisham and Greenwich NHS Trust
- London Borough of Lambeth
- London Borough of Lewisham
Response Status
Linked responses
1 of 3
56-Day Deadline
26 Mar 2025
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 14 February 2023 I commenced an investigation into the death of Naomi SULEYMAN. Ms Suleyman died on 9 February 2023 at University Hospital Lewisham, London (UHL) part of Lewisham and Greenwich Trust (LGT) where she had been admitted from her home on 3 January 2023 with complications of an unstageable pressure ulcer. The investigation concluded on 17 January 2025. I recorded a narrative conclusion:
Naomi Suleyman died from pneumonia and complications of an unstageable sacral pressure sore which she developed having deconditioned and become bedbound following discharge from hospital whilst undergoing assessment of her long-term needs.
Naomi Suleyman died from pneumonia and complications of an unstageable sacral pressure sore which she developed having deconditioned and become bedbound following discharge from hospital whilst undergoing assessment of her long-term needs.
Circumstances of the Death
Ms Suleyman was admitted to UHL on 06.11.22 with pneumonia. She was noted to have a grade 2 sacral pressure ulcer on admission and subsequently developed a sacral deep tissue injury (DTI) requiring the input of the tissue viability nurses (TVN). The DTI appeared to resolve, resulting in her discharge from the TVN caseload, albeit the grade 2 sacral pressure ulcer remained. She was discharged home on 05.12.22 with a package of care arranged through LGT’s and London Borough of Lewisham’s (LBL) integrated multi-disciplinary discharge to assess (D2A) service for assessment of her long-term needs and with a referral to LGT’s District Nursing Service. By 07.12.22 she had developed a new DTI. The DTI progressed to an unstageable pressure sore and she was re-admitted to UHL on 03.01.23 with sepsis from pneumonia and from the sacral pressure sore which had become infected and had progressed to osteomyelitis.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.