North East Kent

Concerns summary A lack of formal communication policy between KMPT and Kent County Council AMHP service caused delays in processing Mental Health Act applications.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary Critical failures in patient monitoring equipment management included staff unawareness of alarm settings, undocumented changes, ignored "OFF COMS" alerts, and unclear protocols for disconnections.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information and compromising safety.

Concerns 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.

Concerns 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.

Concerns summary Neurological observations prescribed after a head injury were discontinued without explanation or documentation, preventing proper monitoring of the patient's condition.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary The hospital failed to complete a home assessment or ensure proper discharge planning, leading to incorrect next of kin notification, unaddressed complex care needs, and the patient being discharged to unsafe living conditions.

Concerns summary Hospital staff failed to investigate a potential fracture after a fall in an elderly patient with dementia, neglecting imaging and over-relying on lack of pain, which led to unaddressed severe injuries and no post-death investigation.

Concerns summary Lack of notification to existing GPs when patient demographic information is updated risks critical communication breakdowns and outdated patient records.