Rashida Sultana
23 Oct 2025 · Coroner Zafar Siddique · Black Country
The coroner's concerns
1. confusion and lack of understanding by nursing staff regarding EMRT activation during emergencies with DNAR
“there was confusion and lack of understanding by nursing staff in relation to when the EMRT should be called in an emergency particularly when a DNAR was place”
2. absence of risk assessment for timing of SALT assessments for dysphagia risk patients
“lack of risk assessment of when SALT assessments for those patients at risk of dysphagia should take place”
3. end-of-life patient with DNAR and multiple comorbidities
“Mrs [name redacted] was approaching end of her life and had a DNAR in place due to her multiple comorbidities”