A CORONER has called on an NHS Trust to address its safeguarding of vulnerable patients who are discharged from hospital following a woman’s death.  

Karen Thomason was discovered dead at her Carlisle home on November 1 - the day after she had been discharged from The Cumberland Infirmary’s A&E department.  

The 52-year-old, who was alcohol dependent, lived in supported accommodation on Oswald Street where she had collapsed on October 31, an inquest heard.

She was taken to hospital after being found by housing manager, Angela Davies, who had asked to be informed if Ms Thomason was to be discharged.

But Ms Davies was not made aware that Ms Thomason had left the hospital later that evening. The doctor in charge of her care said she ‘had capacity’ and there was no medical reason to keep her in hospital.

Ms Davies said she felt it was ‘dangerous’ to discharge her and she had safeguarding concerns.

The coroner said a ‘Prevention of Future Deaths’ report would be issued, asking the hospital to address its safeguarding of vulnerable patients who leave hospital.

Cockermouth Coroners’ Court heard that Ms Thomason was a ‘family orientated’, ‘hard-working’ person who ‘didn’t really drink’ until her life began to deteriorate.

Her mother, Pamela Power, said she was a ‘very honest, loving person’ who ‘fell victim to unpleasant circumstances’ following her divorce.

She had two sons and had previously worked as a carer for the elderly.

On November 1, Ms Thomason was found unresponsive inside her property by Ms Davies, who had been ‘worried’ about her. Emergency services were called but Ms Thomason was pronounced dead.

Dr Clare O’Connell, a consultant in emergency medicine, who had been on shift at the Cumberland Infirmary on October 31, said Ms Thomason had looked ‘alert but dishevelled’.

She was complaining of headaches and disclosed that she had drunk a glass of vodka that day.

Blood tests were taken and the plan was to make sure she had eaten and was mobilised on the department. If she could do this, she was deemed safe to leave, the inquest heard.

Dr O’Connell said Ms Thomason had attended the emergency department ‘many times’ before and there were no features of this admittance that were ‘particularly concerning’.

She said decision-making was shared with individuals who have capacity and it would be ‘unusual’ to discuss this with others.

A toxicology report revealed that Ms Thomason had an alcohol level within a potentially lethal range. The cause of death was acute ethanol toxicity.

Robert Cohen, assistant coroner for Cumbria, concluded that It was an alcohol related death.

Mr Cohen said: “I entirely accept there was no real reason to detain Karen. She had capacity. She was entitled to leave.

“It’s more about the steps the hospital could have taken to alert others of the risks that Karen faced. She lived a very risky life due to the amounts of alcohol she consumed.

“It’s incumbent that hospitals safeguard that person, even if that person doesn’t want to be protected.”

Mr Cohen said he was concerned there was a risk of future deaths.

He said: “In particular, it seems to me that the hospital should be asked to address what steps they took to outline safeguarding concerns to other responsible bodies who could have provided valuable assistance to Karen after she is discharged from hospital.

“I’m concerned that the only angle of safeguarding is, do they have capacity? Do they want to leave the hospital? If they do, you must discharge them.”

Mr Cohen said the hospital, managed by North Cumbria Integrated Care NHS Foundation Trust, should consider if it could have done more to safeguard vulnerable people with nobody to receive them in the community as soon as they leave hospital.

“I will be sending a prevention of future deaths to the hospital, asking them to address that issue,” he added.