Kent and Medway

Coroner Area
Reports: 145 Earliest: Sep 2013 Latest: 24 Mar 2026

70% response rate (above 63% average).

Response Status
Responded 102 No Response 3 Historic 39
AI Classification
Action Taken 61%
Action Planned 25%
Noted 14%
Disputed 0%
Based on 129 classified responses
Top Categories
Hospital Death (Clinical Procedure… (66) Suicide (from 2015) (22) State Custody related deaths (22) Mental Health related deaths (18) Other related deaths (14)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South East average: +63 reports · +10pp response rate
vs national average: +61 reports · +7pp response rate
145 results
Alice Clark
All Responded
2024-0686 24 Oct 2024
South East Coast Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) Unsafe paramedic driving standards were not appropriately addressed due to the lack of a formal complaint procedure and inadequate independent assessment of driver competence.
Action Taken (AI summary) The ambulance service has taken action to address concerns about driving standards complaints, responses, and supervision, including publishing a new driving policy with appendices on speaking up, launching a Speak Up Driving Standards campaign, forming a weekly Driving Standards Review Panel, and embedding Section 19 of the Road Traffic Act 2008.
John Eyre
All Responded
2024-0534 7 Oct 2024
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary (AI summary) There's no clear escalation route for prison healthcare staff to challenge inappropriate prisoner discharges from acute care, nor national guidance for returning prisoners when healthcare concerns are unaddressed by consultants.
Action Taken (AI summary) Medway Maritime Hospital is working with system partners to co-create a written document setting out the process for effective and safe discharges of prisoners and has implemented twice-daily board rounds to discuss patient status. NHS England will share learnings with regional leads.
Megan Williams
All Responded
2024-0518 30 Sep 2024
East Kent Hospitals University NHS Foun… National Institute for Health and Care … NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Deficiencies included unrecorded critical symptoms, poor clinician knowledge of the Acute Abdominal Pain Pathway, a flawed Serious Incident process, and a lack of clear self-discharge procedures.
Noted (AI summary) NICE acknowledges the concerns raised but does not consider any actions from NICE would address the issues. NHS England states that the concerns are local issues for the Trust to address, but that regional colleagues are engaging with the ICB and NHS England will review the Trust's response; also describes national work on PFD reports. East Kent Hospitals is reinforcing the Acute Abdominal Pain Pathway (AAPP) through monthly teaching sessions and case discussions. The AAPP document includes updated patient risk assessment, and the Hospital Discharge and Criteria to Reside Policy was updated to include a checklist for self-discharge.
Sean Davies
No Identified Response CC
2024-0460 8 Aug 2024
HMP Swaleside Ministry of Justice
Suicide (from 2015)
Concerns summary (AI summary) Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. Furthermore, some operational support staff lacked proper training or adhered to it.
Benjamin Harrison
All Responded
2024-0394 19 Jul 2024
HMP Rochester Oxleas NHS Foundation Trust
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) Lack of night-time healthcare in prison means untrained officers manage intoxicated prisoners without clear guidance, compounded by inconsistent information sharing policies between healthcare and prison staff regarding medication and risk.
Action Planned (AI summary) Oxleas will ensure the healthcare team is aware of relevant policies and that these are shared and discussed, and has updated on-call GP guidance. A review of policies has been completed and shared. HMPPS has issued an order to staff regarding escalating concerns about prisoners under the influence of illicit substances. They are also embedding a process for sharing information about at-risk prisoners with medication in their possession, and are consulting on new guidance around prisoners under the influence.
Phephisa Mabuza
All Responded
2024-0487 15 Jul 2024
ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDA…
Mental Health related deaths
Concerns summary (AI summary) The Trust's Crisis Response Service deviated from national guidance by extending mental health triage response times and maintained an incorrectly coded operational policy.
Action Taken (AI summary) Essex Partnership University NHS Foundation Trust acknowledges concerns about their Crisis Response Service (CRS) and triage procedures. They have clarified guidance on the UK Mental Health Triage Scale and rectified a typing error in the Standard Operational Policy regarding triage codes and response times. A memo has been sent to all clinicians within the service reminding them of the use of the UK Mental Health Triage Scale.
Oliver Steeper
All Responded
2024-0290 24 May 2024
Department for Education
Child Death (from 2015)
Concerns summary (AI summary) Early Years Foundation Stage rules allow only one Paediatric First Aid certified staff member, risking inadequate emergency response. Additionally, the three-year PFA certificate validity means staff may not recall critical details in emergencies.
Action Planned (AI summary) The Department for Education is consulting on changes to the EYFS statutory framework, including a new safer eating section and revisions to PFA requirements. They expect to publish the response to the consultation in autumn this year.
Sarah Keen
Partially Responded
2024-0123 4 Mar 2024
Dartford and Gravesham NHS Trust Kent and Medway NHS and Social Care Par…
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Critical patient information, including self-harm risk and medication details, was not communicated to carers. There was also a failure to standardize the understanding of medical abbreviations among staff, impacting patient safety.
Action Taken (AI summary) Darent Valley Trust and Kent Medway NHS and Social Partnership have taken several actions, including reminding staff to record handovers to enhanced care nurses, ensuring that risks to harm are explained, and clarifying responsibilities for medication prescriptions upon discharge; also circulated reminder on avoiding abbreviations in patient records.
Tina Neverland
All Responded
2024-0260 1 Mar 2024
Medway Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) The provided text is truncated and does not detail specific concerns identified by the coroner regarding road safety or circumstances contributing to the death.
Action Planned (AI summary) Medway Council will programme a safety scheme to investigate potential safety enhancements at and approaching the location of the incident on Maidstone Road. Any amendments will be determined by the appropriate and proper study, delivery timescales dependent on scale of amendments.
Kerri Mothersole
All Responded
2024-0122 28 Feb 2024
Kent and Medway Integrated Care Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Private ultrasound reports and images were not consistently provided to treating clinicians or uploaded to hospital notes. The lack of an integrated imaging system for private providers led to missed diagnostic opportunities.
Action Planned (AI summary) Kent and Medway ICB has requested all community diagnostic providers return a signed letter by 30 April 2024, and will review processes and IT integration to improve data sharing, with an options appraisal expected by the end of August 2024.
Richard Hedges
All Responded
2023-0546 19 Dec 2023
Gravesham Borough Council
Other related deaths
Concerns summary (AI summary) An external concrete staircase presented worn, un-highlighted steps lacking non-slip surfaces, an inadequately short handrail, and poor lighting, increasing the risk of falls.
Action Taken (AI summary) The council removed steps and a platform at a bin store to improve safety and accessibility, installed lighting, and removed a similar structure at another location. They believe these actions address all concerns raised.
Roger Stevenson
Partially Responded
2023-0446 13 Nov 2023
Department of Health and Social Care NHS England
Alcohol, drug and medication related deaths Mental Health related deaths
Concerns summary (AI summary) A vulnerable adult with chronic mental ill health was "lost in the system" due to inadequate follow-up, delayed access to services, and lack of proactive support. Staffing shortages and poor family engagement further jeopardized care.
Noted (AI summary) The Department of Health and Social Care outlines existing and planned initiatives to improve mental health support, including increased funding for community mental health services, expansion of NHS Talking Therapies, and investment in crisis care alternatives. They state that responsibility for staffing and operations of mental health services lies with the relevant trust.
Benjamin Hazelden
Historic (No Identified Response)
2024-0026 26 Sep 2023
NHS England NHS Kent and Medway Clinical Commission…
Railway related deaths Suicide (from 2015)
Concerns summary (AI summary) There are severe limitations in suitable specialist placements for young autistic adults with self-harm risks. Past unit closures have created a critical shortage of beds, leading to inappropriate care settings or discharge without adequate support.
Kimberley Sampson and Samantha Mulcahy
All Responded
2023-0338 17 Sep 2023
NHS England Royal College of Obstetricians and Gyna…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Unclear guidance on testing staff for potential infection sources and a lack of national protocols for antiviral therapy in post-partum women with systemic infection, specifically for Herpes Simplex, put patients at risk.
Action Planned (AI summary) NHS England is working to update guidelines on sepsis in pregnancy to include guidance on timely identification and treatment of herpes simplex, scheduled for publication in March 2024; and has a working group to ensure learnings around preventable deaths are shared across the NHS. The RCOG is updating its Green-top Guidelines on maternal sepsis (publication scheduled for March 2024) to include guidance on the timely identification and treatment of herpes simplex.
Barry Lall
All Responded
2023-0385 15 Aug 2023
General Dental Council
Other related deaths
Concerns summary (AI summary) The General Dental Council's practice of publishing extensive, detailed allegations on its website for unconcluded cases can cause significant mental health distress to practitioners who are contesting them.
Action Planned (AI summary) The GDC is undertaking a review of its policy on publishing Interim Order determinations and holding hearings in public, aiming to balance public interest with the interests of the registrant, with the first stage of the review expected to complete by early next year.
Liam Bentley
All Responded
2023-0227 3 Jul 2023
HM Prison and Probation Services
State Custody related deaths Suicide (from 2015)
Concerns summary (AI summary) Critically low and predicted further reductions in prison staff complements compromised the safety of the deceased and pose an ongoing risk due to staff shortages.
Action Taken (AI summary) HMPPS is improving staffing at HMP Swaleside through interventions across pay, recruitment and retention, including a colleague mentor scheme, Advance into Justice, Prison Officer ‘Futures’, the National First Time Officer scheme, locally targeted PR activity, a market supplement and a pay increase.
Benjamin Hart
Historic (No Identified Response)
2023-0113 31 Mar 2023
Kent & Medway NHS & Social Care Partner… NHS Kent and Medway Integrated Care Boa…
Suicide (from 2015)
Concerns summary (AI summary) A severe nursing staff shortfall in the community mental health team prevented patient care coordinator reallocation, highlighting a lack of resilience and capacity in mental health services.
Stefan Kluibenschadl
Historic (No Identified Response)
2023-0068Deceased 19 Feb 2023
NHS Kent and Medway Clinical Commission…
Child Death (from 2015) Suicide (from 2015)
Concerns summary (AI summary) The report identifies a lack of case managers or key workers for young people diagnosed with autism, contrary to NICE guidance, which may prevent them and their families navigating available services.
John Henderson
All Responded
2023-0025Deceased 17 Jan 2023
HM Prison and Probation Service, HMP Ro…
State Custody related deaths
Concerns summary (AI summary) There was no clear process for sharing critical medical information about prisoners with chronic conditions with frontline staff, leaving officers unaware of potential medical emergencies and appropriate responses.
Action Taken (AI summary) Oxleas NHS Foundation Trust has introduced a Personal Management Plan (PMP) in collaboration with HMPPS, which allows healthcare staff to share information with prison officers about prisoners with chronic conditions, including alerts on their NOMIS record and guidance for staff.
Josie Archer-Smith
All Responded
2022-0399 7 Dec 2022
Highways Agency
Road (Highways Safety) related deaths
Concerns summary (AI summary) A specific M20 motorway section has a design flaw, combining an incline and camber, causing water to run across the carriageway and leading to frequent aquaplaning incidents and collisions.
Action Taken (AI summary) National Highways has already undertaken remedial works including drainage cleansing, pipe repairs and installation of kerbs to direct water to the gully. They plan to deliver a Medway and Allington Deck Refurbishment scheme in June-July 2023 which will replace surfacing with Hot Rolled Asphalt and replace vehicle restraint system and drainage to the distributor road.
Sally-Ann Few
All Responded
2022-0366 15 Nov 2022
Medway NHS Foundation Trust
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Critical medication information was lost between GP and hospital systems, leading to incorrect prescribing and potential pain control issues. Additionally, medical record-keeping was poor, failing to document clinical decisions and discussions.
Action Taken (AI summary) The Trust has reminded ENT clinicians to document the reasons for their decisions on daily ward rounds and is sharing a case study on medication reconciliation with pharmacy colleagues at a Controlled Drug Local Intelligence Network meeting. They have also addressed the issue of delayed discharges by requiring conscious decisions to be made regarding recommendations.
Derek Shaw
All Responded
2022-0370 11 Nov 2022
Department of Health and Social Care The Secretary of State for Health and S…
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) A significant delay in ambulance attendance likely contributed to the deceased's death, stemming from systemic capacity issues within local NHS Trusts, not solely the ambulance service.
Action Taken (AI summary) The Department of Health and Social Care highlights that East of England Ambulance Service NHS Trust (EEAST) were under high demand at the time of the incident, and points to improvements in performance this year compared to last year. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and the delivery of new ambulances and specialist mental health vehicles.
Keith Dimond
All Responded
2022-0338 22 Oct 2022
East Kent Hospitals University NHS Foun…
Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths
Concerns summary (AI summary) Significant communication failures led to treating clinicians being unaware of a previous aneurysm diagnosis, resulting in inappropriate treatment. Additionally, patients were discharged on anticoagulants without adequate risk advice, and specialist recommendations were disregarded.
Action Taken (AI summary) East Kent Hospitals University has taken several steps including improving digital record accessibility, emphasizing the importance of clinical history and previous conditions, improving communication regarding patient status and treatment decisions, and providing additional training on Careflow usage.
Robert Brown
Historic (No Identified Response)
2022-0278 20 Sep 2022
Kent and Medway NHS Social Care Partner…
Suicide (from 2015)
Concerns summary (AI summary) “Carer breakdown” was inadequately defined and not addressed during hospital admission or discharge. Without a clear process to involve carers, patients could be discharged without essential support.
Natalie Mortimer
All Responded
2022-0227 25 Jul 2022
Green Porch Medical Centre
Alcohol, drug and medication related deaths
Concerns summary (AI summary) A patient's prior overdose attempt was not updated in their GP record, leading to a GP prescribing a large, potentially unsafe quantity of medication without awareness of the patient's history.
Action Taken (AI summary) The practice has employed a full-time read-coder, introduced a correspondence triage policy, implemented a system for important patient alerts, updated its significant event policy, communicated a case study to clinicians via the GP bulletin (planned actions also to remove the 100-tablet pack size of colchicine from formularies and add a warning message to script switch), placed alerts on patient records for colchicine requests, and is auditing Docman for quality compliance.