Kent and Medway
Coroner Area
Reports: 145
Earliest: Sep 2013
Latest: 24 Mar 2026
70% response rate (above 63% average).
Daniel Ludlam
Partially Responded
2022-0171
7 Jun 2022
Department of Health and Social Care
NHS Digital
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary)
The NHS Pathways triage system lacks specific protocols for patients with learning disabilities, leading to inaccurate symptom communication, potential incorrect triage, and delayed medical assistance.
Action Taken
(AI summary)
The Department highlights NHS Digital's response and notes that protocols exist for 'Early Exit' from NHS Pathways triage, involving clinician takeover when needed, and mentions the Delivery plan for recovering urgent and emergency care services, with £200 million in additional funding in 2023/24 to expand ambulance capacity and improve response times, alongside the delivery of new ambulances and specialist mental health vehicles. They cite improvements in Category 2 ambulance response times.
Hayley Smith
Historic (No Identified Response)
2022-0415Deceased
28 May 2022
Department of Health and Social Care
Other related deaths
Concerns summary (AI summary)
Inadequate communication and fragmented clinical record systems across multiple healthcare organisations led to a critical lack of information sharing, preventing crucial details like a patient's CTO from being known.
Pauline Keen
Historic (No Identified Response)
2022-0152
12 May 2022
Kent and Medway NHS Social Care Partner…
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Other related deaths
Concerns summary (AI summary)
A lack of formal communication policy between KMPT and Kent County Council AMHP service caused delays in processing Mental Health Act applications.
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.
Norman Barnes
Historic (No Identified Response)
2022-0045
14 Feb 2022
Ashley Gardens Care Centre
Care Quality Commission
Care Home Health related deaths
Concerns summary (AI summary)
Care home staff were unaware of crucial dietary requirements and other key information in resident care plans and risk assessments, leading to inadequate and potentially unsafe care delivery.
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.
Lee Thrumble
Historic (No Identified Response)
2021-0304
10 Sep 2021
Department of Health and Social Care
Mental Health related deaths
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information and compromising safety.
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.
Hadley Savory
Historic (No Identified Response)
2022-0402
11 Aug 2021
East Kent Hospital University NHS Found…
Kent and Medway NHS and Social Care Par…
Forward Trust
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
There was no multi-agency planning or established procedures for the safe discharge of patients with complex concurrent mental health, substance misuse, social care, and physical health needs.
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.
Catherine Jux
Partially Responded
2021-0188
2 Jun 2021
Avery Healthcare
Elvy Court Nursing Home
Care Home Health related deaths
Concerns summary (AI summary)
A nursing home failed to complete a patient risk assessment within 24 hours of admission due to oversight, which staff did not notice, indicating an inadequate auditing process.
Action Taken
(AI summary)
The home has revamped its first aid training to include suicide, self-harm, and overdose response, and is providing ligature cutting kits in every office by the end of July 2021. They have also added preventative training around suicide awareness and conversations for all front-line staff.
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.
Matthew Mackell
Partially Responded
2021-0177
25 May 2021
Independent Office for Police Conduct
Kent Police
Child Death (from 2015)
Police related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Kent Police failed to train staff on new phone location software, leading to a critical delay in locating the deceased. Systemic gaps exist in staff knowledge, training, and record-keeping regarding suicide policy and call management.
Action Taken
(AI summary)
Kent Police provides continuous professional development training packages on a 5-week rotation to FCR teams and uses a database to track attendance. The default settings on the Northgate XC mapping system have been configured to ensure that the latest functionality is utilised, and briefings were delivered highlighting the enhanced functionality.
Derek Russell
All Responded
2021-0119
23 Apr 2021
Medway Maritime Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A chronic and long-standing shortage of essential falls alarm equipment at the hospital significantly increases patient risk of falls and fatal injuries, compromising staff's ability to provide safety.
Action Planned
(AI summary)
Medway NHS Foundation Trust is developing a new Standard Operating Procedure and is actively exploring options to source additional falls alarm equipment. A new escalation process will be implemented for non-availability of falls equipment; this will be included in the SOP.
Rodney Gates
All Responded
2021-0070
8 Mar 2021
Medway Maritime Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical patient observations were missed due to low numbers of nursing staff, heavy reliance on agency nurses with limited experience, and a lack of essential equipment on the ward.
Action Taken
(AI summary)
Medway Maritime Hospital has implemented electronic observation recording with a red-flagging system, delivered MHLS training to nurses, trained Band 6 nurses in ALERT and Advanced Life Support, established an acute response team, improved shift handovers, increased A&E staffing, reduced reliance on agency nurses, enhanced the nursing team in Pembroke Ward, and invested in an after-hours equipment store.
Luke Jackson
All Responded
2021-0052
21 Feb 2021
Dept. of Health, Royal College of GPs a…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Medical teams failed to recognise total body potassium depletion in a child with myopathies, leading to insufficient treatment for his complex needs in a standard ward setting.
Noted
(AI summary)
Medway Maritime Hospital updated its paediatric guidelines (version 6.8) and uploaded them to QPulse in March 2021. The updated guidelines include factors that doctors need to be aware of in clinical presentation, assessment requirements, and monitoring levels. RCPCH has shared the report with the British Paediatric Neurology Association (BPNA) to raise awareness on recognising and managing Hypokalaemia. They will discuss hosting a webinar to increase awareness of this case and to promote current NICE guidance, and will also be meeting with the Neonatal and Paediatric Pharmacist Group to discuss case-based discussion podcasts. The Department of Health and Social Care acknowledges the concerns, notes actions taken by the Medway NHS Foundation Trust and the RCPCH, and references NICE guidance on intravenous fluid therapy in children. It states the NICE guidance is not mandatory and does not override clinical judgement.