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
Christopher Smith
Historic (No Identified Response)
2021-0025 3 Feb 2021
Adult Safeguarding Kent County Council Medway NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
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to existing GPs when patient demographic information is updated risks critical communication breakdowns and outdated patient records.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.
Paul Hills
Partially Responded
2020-0247 19 Nov 2020
Ministry of Defence Woolwich Station Medical Centre
Mental Health related deaths Service Personnel related deaths Suicide (from 2015)
Concerns summary (AI summary) Inadequate mental health care during COVID-19 involved no risk assessment for virtual appointments, outdated care plans, failure to share escalating risks with family, and poor documentation of suicidal disclosures.
Action Taken (AI summary) The MOD has taken several steps, including launching the Defence People Mental Health and Wellbeing Strategy in 2017 and a new online platform, HeadFIT, in 2020. Mandatory annual mental health and wellbeing training will be introduced in April 2021, and a Defence Suicide Registry project has begun to inform a MOD suicide prevention strategy.
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.
Yugal Limbu
Historic (No Identified Response)
2020-0176 14 Sep 2020
Ashford Borough Council Kent County Council
Other related deaths
Concerns summary (AI summary) A hazardous gap and sloped surface by a footbridge in a public park pose a danger to users, especially at night, with unclear responsibility between local authorities.
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.
Harry Richford
Partially Responded
2020-0117 3 Feb 2020
Department of Health and Social Care, N… The Chief Coroner
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The provided text introduces the concept of "Concern 1" but does not detail any specific issues or findings.
Action Taken (AI summary) The Department of Health and Social Care outlined actions taken by health regulators and system partners to scrutinise and support the safety of maternity services at the East Kent Hospitals University NHS Foundation Trust, including a CQC inspection and engagement with families. They commissioned an independent review into maternity services at East Kent Hospitals.
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.
Dorothy Macey
Historic (No Identified Response)
2019-0388 13 Nov 2019
Medway Community Healthcare
Community health care and emergency services related deaths
Concerns summary (AI summary) Failures in district nurse care included not photographing wounds, poor information sharing with GPs about treatment delays, incomplete electronic records, missed sepsis checks, and inadequate care plan updates.
Daphne Wigley
Historic (No Identified Response)
2019-0266 20 Aug 2019
Medway Maritime Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The report provided no specific details regarding the matters of concern, indicating a placeholder or incomplete entry.
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.
Mildred Clark
Historic (No Identified Response)
2019-0127 25 Apr 2019
East Kent University Hospitals NHS England South East Coast Ambulance Service
Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A paramedic was inappropriately instructed to perform an untrained hernia reduction, causing pain, when the patient should have been transferred to hospital for a suspected strangulated hernia, possibly due to pressure to avoid admissions.
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.
Christopher Innes
Partially Responded
2019-0124 10 Apr 2019
Kent County Council Regent Coaches in Whitstable, Kent
Road (Highways Safety) related deaths
Concerns summary (AI summary) An unmarked bus stop on a 50mph road without pedestrian facilities created a hazard for alighting passengers, exacerbated by overgrown vegetation and unclear management responsibility.
Action Planned (AI summary) KCC plans to install pedestrian crossing road warning signs by September 2019 and additional signs for the Mansfield Farm site. Vegetation clearance will be added to a cyclic programme if landowner agreement is obtained. They will recommend the re-installation of the Hail and Ride bus service following the installation of pedestrian crossing signs and the removal of vegetation.
Timothy Mason
Partially Responded
2018-0351 26 Oct 2018
Maidstone & Tunbridge Wells NHS Trust NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Failures in the Emergency Department led to incorrect diagnosis and treatment of sepsis, and the discharge of an unwell patient. Concerns include inadequate staff instructions, training, and systems for providing the Men ACWY vaccination.
Action Taken (AI summary) The Saxonbury House Medical Group has switched on alerts prompting the offer for patients who have not received the Men ACWY vaccination and has written to EMIS requesting that Men ACWY is added to the list of vaccines flagged up in the alert box as a routine. All local practices have been written to and asked to check that the Men ACWY vaccination alert is activated and patients invited from the relevant cohort.
John Lee
Historic (No Identified Response)
2018-0349 19 Oct 2018
Medway NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A clerical error severely delayed an urgent vascular appointment, changing an elective procedure to an emergency and contributing to the patient's death, highlighting issues with ambiguous terminology and inadequate checking systems.
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.
Bernard Fagg
Historic (No Identified Response)
2018-0245 17 May 2018
Medway NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns exist over whether patients undergoing CT scans with contrast and subsequent nil-by-mouth procedures should receive intravenous fluids, due to potential dehydration risks.
Paul James
Partially Responded
2018-0254 27 Apr 2018
HMP Elmley THE SECRETARY OF STATE FOR JUSTICE
State Custody related deaths
Concerns summary (AI summary) A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting inadequate risk assessment and safety protocols for vulnerable individuals.
Action Planned (AI summary) HM Prison & Probation Service will issue a learning bulletin on managing razor blade risks, pilot a revised ACCT case management process prompting consideration of razor blade access, and consider broader options for managing the issue.
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.