An inquest into the death of a young woman in London with insulin-dependent diabetes was partly caused by her early release from hospital.
The inquest into the death of a young woman in London was contributed to by premature discharge from St George’s Hospital, a coroner has concluded.
Charlotte Lindsay, 29, was found by a district nurse on 17 October 2021, three days after her discharge from St George’s Hospital.
The inquest heard that nursing staff had visited Lindsay’s room on multiple occasions in the period after she had died but had not seen her body and had left without being aware she had died.
“It is the family’s view that Charlotte should not have been discharged back to Dunheved Hotel, as it was not safe for her,” said Tiffany Bucknall, human rights solicitor at Leigh Day and who represented the family.
“During the inquest, we raised concerns about the fact that Charlotte’s family were not involved in the discharge decision, and that were inadequate frameworks in place for liaison and information sharing between the NHS Trusts and the Local Authorities that could have allowed for alarm bells to be sounded ahead of Charlotte being discharged,” she continued.
Risk in being discharged
Lindsay had insulin-dependent diabetes and a severe needle phobia. She had been in hospital for over four months due to a leg injury and subsequent complications, including issues with control of her blood glucose levels and hypertension.
She was dependent on renal dialysis, due to end-stage kidney failure. Throughout her hospital admission, concerns were raised about Lindsay’s vulnerability, particularly around her inability to self-administer insulin, her mobility, complex health conditions, and poor mental health.
Throughout her admission, hospital staff identified significant risks in Lindsay being discharged to the Croydon Dunheved Hotel.
The inquest heard that two days before Lindsay’s discharge, a consultant had noted that the patient was medically fit for discharge, but had an “unsafe social set up. Despite this, she was discharged two days later.
The coroner found that the decision to discharge Lindsay from St George’s Hospital was made “without the required holistic overview of all health and social care needs, that there was no consideration of the significance of the limited capacity to summon help from her basement flat”.
“The evidence heard at the inquest highlighted a series of failures in communication and coordination amongst all organisations involved, and showed the impact that can occur when no single organisation or person takes responsibility for or has oversight of the needs of an individual in their care,” said Bucknall.
