Naomi SULEYMAN · Prevention of Future Deaths report

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 NHS 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.

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.

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.