Kent and Medway
Coroner Area
Reports: 145
Earliest: Sep 2013
Latest: 24 Mar 2026
70% response rate (above 63% average).
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.
Betty Tadman
All Responded
2021-0023
1 Feb 2021
Medway NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
Medway Maritime Hospital will present the case as a study at a multidisciplinary Grand Round session. The Trust is committed to implementing a "silver trauma" screening system in ED and plans to adopt the London Major Trauma System for elderly patients, and already introduced a "front door" team of specialist nurses to assess elderly frail patients in ED.
Ronald Tilley
All Responded
2020-0278
4 Dec 2020
NHS Digital
Community health care and emergency services related deaths
Other related deaths
Concerns summary (AI summary)
Lack of notification to existing GPs when patient demographic information is updated risks critical communication breakdowns and outdated patient records.
Action Planned
(AI summary)
NHS Digital will bring the circumstances surrounding the death to the attention of a programme that is rationalising and streamlining the systems and data flows in the management of primary care registration. This is so that improvements may be considered through appropriate consultation with system users and stakeholders.
William Israel
All Responded
2020-0271
3 Dec 2020
London and South Eastern Railway
Railway related deaths
Concerns summary (AI summary)
Public misunderstanding of live rail dangers is exacerbated by inadequate, outdated, and poorly placed warning signage, alongside inconsistent station security measures when unstaffed.
Action Planned
(AI summary)
Southeastern will replace warning signs at Canterbury East station, engage with a local nightclub to educate patrons about railway safety, review risk assessments for the station, and share findings with the wider railway community. Most actions are planned for completion by March/June 2021. Southeastern replaced warning signs at Canterbury East station with a new design. They also provided Chemistry Night Club with posters and drinks mats highlighting railway safety messages, reviewed risk assessments, and shared learning with the wider industry.
Katherine Hogan
All Responded
2020-0243
18 Nov 2020
Maidstone and Tunbridge Wells NHS Found…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Persistent staff shortages led to patients being kept overnight in unsuitable clinical areas, with the Trust failing to address reported staffing issues or implement requested increases.
Action Taken
(AI summary)
The Trust has implemented several changes including increased monitoring of patients in the clinical decision unit (CDU), revised admission criteria for the CDU, reassessed safe staffing levels, increased senior nursing support, and is using RCEM/GIRFT recommendations for staffing. It has also re-opened the serious incident investigation and is creating a revised action plan.
Daniel Waite
All Responded
2020-0241
16 Nov 2020
Highways Department Kent County Council…
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The A20 Ashford Road lacks parking restrictions and requirements for warning signage, allowing large vehicles to park unsafely and posing a significant risk to other road users.
Action Taken
(AI summary)
Kent County Council has installed 'clearway' signs and implemented a temporary traffic regulation order prohibiting parking on the section of dual carriageway. A permanent traffic regulation order with permanent posts and signage will replace the temporary order.
Martin Barrett
All Responded
2020-0222
27 Oct 2020
Priory Group
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
When internal referrals are declined, patients are not directly informed or given safety netting advice, particularly with insurance funding, leaving high-risk individuals without immediate alternative treatment or support.
Action Taken
(AI summary)
The Corporate Client Team now makes direct contact with all newly referred clients. Guidance has been put in place for the CCT on actions to take if a client is experiencing an immediate crisis. An appointment with a consultant psychiatrist is now booked to take place in the same week as the therapy assessment, and therapists have been given guidance on the advice that they should give to any newly referred clients who they feel are higher risk.
Lynda Pedersen
All Responded
2020-0112
15 May 2020
East Kent University Hospital NHS Trust
NHS England NHS Improvements
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A lack of clear pathways for dysphagia and a missed opportunity to investigate for malignancy, alongside poorly completed fluid balance charts that failed to identify a critical fluid overload, contributed to the death.
Noted
(AI summary)
The Trust has undertaken multidisciplinary education programmes on accurate fluid balance monitoring and audits completion of fluid balance charts; clinical staff complete clinical induction days, and critical care outreach teams provide support and teaching to ward staff. NHS England states that while they do not develop clinical pathways, national bodies have, and hopes that this case has been used at the Trust for reflection, learning, and action.
Terence James
All Responded
2019-0430
17 Dec 2019
Charing Healthcare
Care Home Health related deaths
Concerns summary (AI summary)
The care home failed to promptly inform medical professionals about falls, adequately handover patient history, or escalate concerns about a patient's deteriorating condition.
Action Taken
(AI summary)
The organisation has conducted team meetings and supervision sessions and is introducing a specific audit relating to the handover process from 29 January 2020. They have reviewed and updated robust systems and ensured they are in place.
Callie Lewis
All Responded
2019-0414
3 Dec 2019
Department of Digital, Culture, Media a…
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
An online suicide forum provided dangerous advice, enabling individuals to mislead mental health professionals and perfect suicide methods, thus frustrating necessary assessments and interventions.
Action Planned
(AI summary)
The DCMS outlines the Online Harms White Paper, which proposes a duty of care for companies to protect users online, overseen by an independent regulator. They have also convened a working group of social media companies to explore further safety measures and have held summits with social media providers regarding suicide and self-harm content.
Jonathan McCarthy
All Responded
2019-0179
22 May 2019
Maidstone & Tonbridge Wells NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Trust failed to correctly monitor blood sugar and ketones, administered incorrect insulin, and provided inadequate nursing care with a failure to escalate concerns.
Action Taken
(AI summary)
The Trust has created a guideline for capillary blood glucose monitoring, implemented monthly training for staff, and introduced new blood glucose meters with enhanced data capture. The Trust has raised awareness through the Patient Safety Calendar, a launch of the Blood Monitoring Guideline and bespoke Training days for Nurses and Clinical Support Workers.
Jennifer Lewis
All Responded
2019-0003
15 Apr 2019
Oxleas NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There was a failure to coordinate care between mental and physical health doctors, resulting in unsuitable and inadequate care for the patient's overall needs.
Action Taken
(AI summary)
The Trust has implemented several changes, including inviting relevant healthcare professionals to CPA meetings, entering all patients' weight and height into the Malnutrition Universal Screening Tool (MUST), and ensuring patients with long-term nutritional needs remain open to the dietician. These improvements are incorporated into the physical health strategy.
Taiyah-Grace Peebles
All Responded
2018-0239
24 Jul 2018
Network Rail
Railway related deaths
Concerns summary (AI summary)
Many railway platforms lack barriers to prevent accidental contact with live rails, which pose a significant electrocution risk compared to safer overhead power systems used elsewhere.
Action Taken
(AI summary)
Platform-end gates have been installed at 30 locations in Kent and Sussex. £800,000 of work is due to be completed by April 2019 to improve fencing at higher risk areas.
Peter King
All Responded
2017-0414
20 Nov 2017
East Kent Hospitals University NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Multiple deaths resulted from inadequate, incomplete, or unenforced falls risk assessments on the ward, including poor documentation, lack of intervention, and failure to address risks at handover.
Action Taken
(AI summary)
The Trust monitors patient falls monthly as part of its quality indicators and has introduced SafeCare to enable ward staff to see if their staffing levels match demand; a full time band 4 Associate Practitioner for Falls Prevention joined the team in September 2017.
Harold Wonfor
All Responded
2017-0408
20 Nov 2017
East Kent Hospitals University NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Multiple deaths occurred on a ward due to inadequate, incomplete, and unenforced falls risk assessments. Policies for vulnerable patients and the monitoring of falls prevention procedures were insufficient.
Action Taken
(AI summary)
The Trust monitors patient falls monthly as part of its quality indicators and has introduced SafeCare to enable ward staff to see if their staffing levels match demand; a full time band 4 Associate Practitioner for Falls Prevention joined the team in September 2017.
Claire Medhurst
All Responded
2017-0270
10 Aug 2017
Medway NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The discharge process lacked crucial cautionary advice on medication use, and treating clinicians failed to receive alerts for abnormal liver function and toxic paracetamol levels.
Action Taken
(AI summary)
The Trust will provide feedback to relevant staff regarding cautionary advice on analgesics and has discussed this in Emergency Department safety huddles. An algorithm has been written to add a paracetamol to phone trigger test, and a flagging system implemented for ALT levels outside of the safe range.
Luke Mumford
All Responded
2017-0047
23 Feb 2017
Kent County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The road's narrow, unlit, and unkerbed characteristics, bordered by hedgerows, make the 70 mph speed limit unsafe, with experts stating speeds above 50 mph pose significant risks.
Action Planned
(AI summary)
Kent County Council will program a scheme to reduce the speed limit of the road to 50mph and will investigate a Crash Remedial Measure to seek to improve the 'safety' of this dual carriageway.
Frances Cappuccini
All Responded
2017-0020
27 Jan 2017
Maidstone and Tunbridge Wells NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Multiple failures included not checking for retained placenta, ignoring haemorrhage protocols, inadequate anaesthetist supervision, delays in emergency help, and poor note-keeping, all impacting patient safety.
Action Taken
(AI summary)
The Trust detailed standard practice for checking placenta removal and monitoring blood loss after caesarean sections. They described actions to improve diagnosis and treatment of Postpartum Haemorrhage (PPH), including training, equipment, PPH boxes and proformas. Also described documentation training and audits for staff.
Natalie Gray
All Responded
2017-0003
13 Jan 2017
Kent and Medway NHS
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Concerns included an unfinalized discharge pathway for personality disorder patients, inadequate risk assessment forms and subjective terminology leading to inaccurate assessments. Crucially, significant third-party information was not consistently recorded.
Action Taken
(AI summary)
The Trust has implemented steps to support discharge from in-patient services, including using a countdown to discharge tool and strengthening links between CMHT and CRHT teams. The Trust is improving relationships with Kent Police by designating a third police officer to the acute service line and holding quarterly executive liaison meetings.
Ronnie Olliffe
All Responded
2016-0224
15 May 2016
HMP Rochester
State Custody related deaths
Concerns summary (AI summary)
There was a failure to issue a Code Blue appropriately, a lack of understanding about its emergency consequences, and a failure to use an available defibrillator.
Action Taken
(AI summary)
Following a failure to issue a Code Blue, all night staff at HMP&YOI Rochester were issued copies of PSI 03/2013 and signed to confirm understanding. A Notice to Staff was issued and pocket-sized cards explaining the codes were ordered for all staff, and a defibrillator demonstration was provided.
Lillian Hursell
All Responded
2016-0129
1 Apr 2016
Ranc Care Home Ltd
Care Home Health related deaths
Concerns summary (AI summary)
Faulty bedrail mechanisms led to instability, and staff provided inappropriate first aid after a patient's fall by moving her without assessing potential head and neck injuries.
Action Taken
(AI summary)
The care home has commenced retraining in first aid, moving and handling, and health and safety. They have introduced bedrail audits, re-educated staff in bed rail use, and advised staff not to move a person following a fall until assessed.
Alwyn Head
All Responded
2016-0115
23 Mar 2016
Medway NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient safety.
Action Taken
(AI summary)
The Trust introduced new admission/transfer documentation for patient infection status, is providing staff training, and implemented ward-to-board rounds. A Deteriorating Patient Programme and a Sepsis Action Group are in place, and the Trust has provided feedback to the NICE consultation on the proposed new Sepsis Guidance.
Sandra Wood
All Responded
2016-0048
12 Feb 2016
Maidstone and Tonbridge Wells NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The NHS Trust's lack of routine weekend CT scan facilities led to a critical delay in an urgent scan, proving too late for the patient.
Noted
(AI summary)
The Trust states they do have facilities to provide CT scans during weekends and that scans are carried out on all patients that require them, based on a clinical decision; the Trust has taken the opportunity to re-iterate the processes in place to clinical staff regarding the availability of CT scanning 24/7 for urgent cases.