North East Kent

Coroner Area
Reports: 143 Earliest: Sep 2013 Latest: 10 Feb 2026

68% response rate (above 62% average).

Response Status
Responded 97 No Response 1 Historic 34 Pending 6
AI Classification
Action Taken 76%
Action Planned 6%
Noted 12%
Disputed 6%
Based on 33 classified responses
Top Categories
Hospital Death (Clinical Procedure… (66) State Custody related deaths (22) Suicide (from 2015) (21) Mental Health related deaths (18) Other related deaths (14)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South East average: +62 reports · +8pp response rate
vs national average: +60 reports · +6pp response rate
143 results
William Israel
All Responded
2020-0271 3 Dec 2020
London and South Eastern Railway
Railway related deaths
Concerns summary Public misunderstanding of live rail dangers is exacerbated by inadequate, outdated, and poorly placed warning signage, alongside inconsistent station security measures when unstaffed.
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Concerns summary Inadequate mental health care during COVID-19 involved no risk assessment for virtual appointments, outdated care plans, failure to share escalating risks with family, and poor documentation of suicidal disclosures.
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 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.
Daniel Waite
All Responded
2020-0241 16 Nov 2020
Highways Department Kent County Council…
Road (Highways Safety) related deaths
Concerns 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.
Martin Barrett
All Responded
2020-0222 27 Oct 2020
Priory Group
Mental Health related deaths Suicide (from 2015)
Concerns 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.
Yugal Limbu
Historic (No Identified Response)
2020-0176 14 Sep 2020
Ashford Borough Council Kent County Council
Other related deaths
Concerns 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 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.
Harry Richford
Partially Responded
2020-0117 3 Feb 2020
Care Quality Commission General Medical Council Department of Health and Social Care +3 more
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The provided text introduces the concept of "Concern 1" but does not detail any specific issues or findings.
Terence James
All Responded
2019-0430 17 Dec 2019
Charing Healthcare
Care Home Health related deaths
Concerns 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.
Callie Lewis
All Responded
2019-0414 3 Dec 2019
Department for Culture, Media and Sport
Mental Health related deaths Suicide (from 2015)
Concerns 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.
Dorothy Macey
Historic (No Identified Response)
2019-0388 13 Nov 2019
Medway Community Healthcare
Community health care and emergency services related deaths
Concerns 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 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 The Trust failed to correctly monitor blood sugar and ketones, administered incorrect insulin, and provided inadequate nursing care with a failure to escalate concerns.
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 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 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.
Christopher Innes
All Responded
2019-0124 10 Apr 2019
Kent County Council
Road (Highways Safety) related deaths
Concerns 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.
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 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.
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 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 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.
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 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
All Responded
2018-0254 27 Apr 2018
HMP Elmley
State Custody related deaths
Concerns 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.
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 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.
Henry Honour
Historic (No Identified Response)
2017-0413 20 Nov 2017
East Kent Hospitals University NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Multiple deaths on a ward were linked to inadequate or unenforced falls risk assessments. Specific to this case, the assessment was perfunctory, bed rails were misused, and no protective measures were implemented post-fall.
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 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.
Claire Medhurst
All Responded
2017-0270 10 Aug 2017
Medway NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.