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
Clear 86 results
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.
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.
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.
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.
Kathryn Millard
All Responded
2022-0121 25 Apr 2022
Medway NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical treatment plans were undocumented and unimplemented, nursing staff were unaware of key medical directives, and unidentified staff failed to record patient reviews despite deterioration concerns.
Action Taken (AI summary) The Orthopaedic team discussed the outcome of the Serious Incident Investigation report at the junior doctor’s grand round, and medical doctors have been reminded of effective healthcare record keeping. Nursing staff have received training towards routine anti-embolic stocking application. The trust has shared the outcome of the SI investigation, changed the ward-based structure to team-based, ensured good record keeping, and provided nursing training towards routine TED application. Documentation on EPR was audited in January 2022.
Emma Pring
All Responded
2022-0105 3 Apr 2022
Interweave
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Product related deaths Suicide (from 2015)
Concerns summary (AI summary) "Anti-ligature" safety clothing failed, allowing self-harm and potentially providing staff with false reassurance. Older, riskier versions of the product remain in circulation, requiring urgent action.
Action Taken (AI summary) Interweave Textiles Ltd. notified customers who had been supplied with similar products, recommending they check their stock for damage and reminding them to check garments before use and dispose of damaged ones, as well as reviewing and updating care instructions.
Samuel Alban-Stanley
All Responded
2022-0082 12 Mar 2022
Department of Health and Social Care NHS Kent and Medway Clinical Commission…
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Other related deaths
Concerns summary (AI summary) Inadequate support and psychosocial interventions were provided for a child with Prader Willi syndrome and high-risk behaviours. Poor communication between agencies also prevented coordinated care.
Action Planned (AI summary) North East London Foundation Trust is working with the Kent and Medway ICS and the local authority to learn lessons from the report, and has put training in place for all relevant staff on the signs and impacts of the relevant condition, and introduced reviews for high complexity cases. Training on Prader-Willi syndrome has been provided to CYPMHS staff at NELFT, and joint posts have been created across the Local Authority and Primary Care to identify children with additional needs early. Kent has also mobilised the National NHS England Designated Key Worker Early Adopter programme and continues to develop programmes for early intervention and support. The Department for Education is working with the Children’s Commissioner’s Office and the Information Commissioner’s Office (ICO) to identify ways to better improve data sharing in child safeguarding cases. They have also committed to publishing an ambitious implementation strategy later this year.
Christopher Osland
All Responded
2022-0060 22 Feb 2022
East Kent Hospitals University NHS Foun…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The report identifies that nursing staff were unaware that the room monitor volume could be reduced to inaudible levels, circumstances were undocumented, and no steps were taken to respond to a persistent 'OFF COMS' notification.
Action Taken (AI summary) The hospital describes changes to alarm volume settings on room monitors, restricting ICU staff from adjusting them and assigning control to the EME department. They also describe updates to the process for reporting issues with the central monitoring system and implementing twice-daily audit checks.
Idris Habib
All Responded
2022-0020 24 Jan 2022
HMP Swaleside
Mental Health related deaths State Custody related deaths
Concerns summary (AI summary) Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect also existed between prison policy and officers' actions.
Action Taken (AI summary) HMP Swaleside issued a notice in November 2021 reminding staff of cell clearance procedures and reinforced the process during staff briefings. Since the inquest, the prison has introduced a welfare check at approximately 8am requiring staff to gain a verbal response from the occupant, with completion of the check recorded in the wing assurance book, with staff re-issued a notice to remind them to satisfy themselves of the prisoner's wellbeing.
Terence Talbot
All Responded
2021-0419 3 Dec 2021
Department for Work and Pensions Kent & Medway Social Care Partnership T… Maidstone & Tunbridge Wells NHS Foundat…
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Other related deaths
Concerns summary (AI summary) Inadequate clinical assessments, including mental capacity and specialist dermatology review, combined with insufficient nutritional care, and a rigid DWP policy requiring a critically ill inpatient to attend in person for benefits.
Noted (AI summary) Maidstone Hospital has implemented an action plan, recorded in their incident reporting system (DATIX), and taken steps to strengthen multi-professional working with Kent and Medway Social Care Partnership Trust. They have also commissioned an audit into consent and capacity practices and appointed a new clinical advisor and practitioner for capacity. Kent and Medway NHS and Social Care Partnership Trust have improved joint working with Maidstone and Tunbridge Well NHS trust, strengthened Mental Capacity Assessment monitoring, closely monitored Mental Capacity Act training and signed a Service level agreement with MTW to support patients detained under the Mental Health Act. The DWP outlines its procedures for vulnerable claimants, including reasonable adjustments for those unable to attend in person. They state that they are satisfied that appropriate support is available and do not propose to take any specific actions or make any changes at this time.
Christian Hinkley
All Responded
2021-0376 4 Nov 2021
Minister of State for Prisons and Proba…
State Custody related deaths
Concerns summary (AI summary) Prison fire detection systems are inadequate and unable to reliably detect cell fires early enough to save lives. Despite repeated warnings and notices issued since 2015, in-cell automatic fire detectors remain uninstalled.
Action Taken (AI summary) HMPPS is investing £315m to improve fire safety, including in-cell fire detectors, portable fire detection devices, water mist firefighting equipment, and smoke ventilation fans. Cell fire response training was revised in December 2021 to include scenarios for obstructed inundation ports.
Caden Stewart
All Responded
2021-0328 4 Oct 2021
HMYOI Cookham Wood
Child Death (from 2015) State Custody related deaths
Concerns summary (AI summary) Prison staff were unaware of relevant policies, and there was a critical lack of communication among officers regarding a prisoner's unwell status and need for healthcare, leading to missed checks and handovers.
Action Taken (AI summary) In September 2021, HMP Cookham Wood issued a Notice to Staff reminding PE staff of PSI 58/2011 requirements and introduced daily roll books to record time spent in activities and healthcare requests. The logs provide for comments to be added and ‘guidance prompts’ are now in place which outline the importance of providing this information so that it is available to all staff.
Hadley Savory
All Responded
2021-0270
Kent County Council
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Other related deaths
Concerns summary (AI summary) There was no multi-agency planning for complex patient discharge, and internal disagreements regarding case allocation were not recorded. Information sharing for patients with fluctuating mental capacity was unclear, and care needs were not consistently met.
Action Taken (AI summary) Kent County Council has implemented multi-agency protocols and tools for patient discharge, including risk management plans and care planning guidance. Staff training on these protocols and mandatory safeguarding awareness training has been delivered, and information sharing processes have been reviewed and updated.
Steve Cooke
All Responded
2021-0266 8 Aug 2021
South East Coast Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) Critical communication failures by emergency operations control, including dispatching an ambulance to the wrong address and inadequate follow-up with contacts, led to a severely unwell patient not being located.
Action Planned (AI summary) South East Coast Ambulance Service is updating its processes for 999 and 111 calls to ensure call handlers ask for the address instead of suggesting it, and improving the process for when crews cannot locate a patient by escalating to a team leader who will verify the address and search for additional information; these changes will be implemented via operational bulletins expected to be in force within 1-2 weeks.
Fred Reynolds
All Responded
2021-0241 15 Jul 2021
Kent and Medway Social Care Partnership…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Neurological observations prescribed after a head injury were discontinued without explanation or documentation, preventing proper monitoring of the patient's condition.
Action Taken (AI summary) The trust has implemented electronic monitoring of observations, employed specialist Physical Health Nurses, and developed a Trust-wide “Train the Trainer” course for neurological observations and the Glasgow Coma Scale for all physical health nurses. They also disseminated a learning bulletin reiterating the need for neurological observations.
Johanna Moreland
All Responded
2021-0240 11 Jul 2021
Medway NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant delays occurred in obtaining urgent lumbar puncture results and starting antiviral treatment. Additionally, post-liver biopsy observation protocols were not followed due to miscommunication and poor record-keeping.
Action Taken (AI summary) The Trust has developed a handover form to be completed post every procedure led by the Consultant Radiologist with written confirmation of observation frequency and handover to nursing staff. The Trust has reiterated post-procedure observation policy to all nursing staff through consistent inclusion in the Trust’s ‘Big 4’ ward-based messaging.
Eleanor Rose Murphy-Richards
All Responded
2021-0237 11 Jul 2021
North East London NHS Foundation Trust
Child Death (from 2015) Mental Health related deaths Railway related deaths Suicide (from 2015)
Concerns summary (AI summary) The Child & Adolescent Mental Health Centre lacked protocols for Mental Health Act assessments and failed to create an adequate safety plan with clear responsibilities and contingencies for non-attending patients. Crucially, relevant information about a suicide attempt was not fully shared, and police advice didn't account for absconding history.
Action Planned (AI summary) The Trust is developing an updated electronic risk assessment proforma to prompt a review of the existing safety plan. The Trust will update its training for all staff in relation to the importance of safety plans and contingency planning and has arranged a meeting with the family to share learning and provide further reassurance in respect of improvements made within the service.
James Devenny
All Responded
2021-0179 25 May 2021
HMP Elmley and Director General – Priso…
Mental Health related deaths State Custody related deaths Suicide (from 2015)
Concerns summary (AI summary) Prisoners lack direct access to Samaritans, relying on staff, which is especially difficult for those with violence risks. Prison officers are not routinely briefed on prisoners' significant self-harm history.
Action Taken (AI summary) HMP Elmley has equipped nearly all cells with in-cell phones and ensures access to Samaritans. ACCT version 6 has been rolled out across the male estate and training modules and awareness materials have been made available to all staff. The prison also operates a Key Worker scheme and uses an updated safety diagnostic tool.