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recurance

Leslie Lerner

28 Oct 2016 · Coroner Veronica Hamilton-Deeley · Brighton and Hove

The coroner's concerns

  1. 1. inappropriate sling application

    “Junior Doctor applied wrong sling with wrong knot for Mr [name redacted] after she had learned that he had had a fractured shoulder which was to be treated conservatively”
  2. 2. premature discharge without senior review

    “Mr [name redacted] was kept in the Royal Sussex County Hospital overnight and i towards the middle of the day he was discharged without a Senior Review”
  3. 3. delayed analgesia administration

    “Mr [name redacted] was back at the RSCH, by ambulance at 1006 hrs in considerable pain and discomfort.”
  4. 4. failure to implement orthopaedic recommendation

    “Having been admitted to a renal ward, because of lack of beds elsewhere, a member of the medical staff had a telephone discussion with a member of the Orthopaedic Team and a collar and cuff sling was recommended. This information was not passed onto the Nursing Staff, not properly documented nor was the Patient actually seen by a member of Orthopaedic Team”
  5. 5. lack of continuity and hands-off care

    “There is no evidence of any continuity of care.”
  6. 6. delayed recognition of sling-induced injury

    “This was the day (nine days after its application) that hospital staff realised that the sling was incorrectly tied, and of the wrong type, and had caused a long deep Grade 2 pressure sore and necrotic ulcerated area where it had been pressing into the back of Mr [name redacted] neck”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Leslie Lerner · Recurance