Naomi Suleyman

Lewisham and Greenwich NHS Trust 
University Hospital Lewisham 
Lewisham High Street 
London 
SE13 6LH 

Ms Liliane Field                                                                                             
Assistant Coroner for London Inner South 
1 Tennis Street 
Southwark 
London SE1 1 YD 

26th March 2025 

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. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  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 
2 

 
 
 
 
 
 
 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. 

3 

 
 
 
 
 
 •  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 
followed.  These 
oversee 
communication efforts are being actively monitored and evaluated to confirm their 
effectiveness in preventing any future issues. 

this  process  and  ensure 

that  care  plans  are 

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.  

Yours sincerely 

Chief Medical Officer 
Lewisham and Greenwich NHS Trust   

Interim Executive Director 
Adult Social Care & Health  
London Borough of Lewisham 

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