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
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 (AI 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.
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.
Robert Mullis
Partially Responded
2017-0166 23 May 2017
Network Rail South Eastern Railways
Railway related deaths
Concerns summary (AI summary) A vulnerable, partially sighted patient with dementia was able to disembark a high-speed train unaccompanied and access railway tracks directly from the end of the platform.
Action Taken (AI summary) Network Rail has installed platform-end fencing and anti-trespass panels on platforms 2, 5, and 6 and the London end of platform 1 at Ashford International Station. Equivalent fencing will be installed at the country end of platform 1 by the end of July 2017.
Andrew Wilson
Historic (No Identified Response)
2017-0152 8 May 2017
East Kent Hospital Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) No arrangements existed to provide peritoneal dialysis at non-renal hospitals, and treating clinicians were unaware of this service gap or the unavailability of trained staff and equipment.
Sian Hollands
Historic (No Identified Response)
2017-0129 20 Apr 2017
Dartford and Gravesend NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns include inadequate training on patient scoring systems, a failure to provide doctors with nurses' medical notes, and doctors' failure to correctly diagnose pulmonary embolism.
Jamie Fairclough
Historic (No Identified Response)
2017-0119 12 Apr 2017
Kent and Medway NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Excessively high caseloads for Care Co-ordinators, often exceeding 75-80 service-users, compromised the quality of patient care and staff's ability to manage their responsibilities.
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.
Denis Plater
Historic (No Identified Response)
21 Nov 2016
MEDICSPRO MEDWAY NHS FOUNDATION TRUST
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Incomplete medical records, an agency nurse's failure to correctly apply and escalate patient conditions using the NEWS scoring system, and inadequate monitoring of agency staff training.
Jonathan Fry
Historic (No Identified Response)
2016-0193 16 May 2016
Medway NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was a lack of senior consultant review, inadequate daily review of test results, and inconsistent medical records, leading to a lack of clarity in patient care and planning.
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.
Thomas Harris
Historic (No Identified Response)
2016-wp25258 28 Apr 2016
Right Honourable Theresa May MP
Product related deaths Suicide (from 2015)
Helen Turner
Historic (No Identified Response)
2016-0159 14 Apr 2016
East Kent Hospitals University NHS Foun…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical delays in diagnosing a sigmoid colon obstruction and subsequently performing stenting and surgery led to a severe deterioration in the patient's condition. These delays significantly reduced her chances of survival.
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.
Matthew Crowley
Historic (No Identified Response)
2016-0063 17 Feb 2016
Maidstone and Tunbridge Wells NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A&E delays due to short-staffing prevented timely triage and immediate senior doctor review. There was a delay in patient ownership, decision-making, and communication failure during transfer to ITU.
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.
Joanna Bowring
All Responded
2016-0027 27 Jan 2016
Kent and Medway NHS and Social Care Par…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding of services or a care plan.
Action Taken (AI summary) The Trust re-launched its carers protocol in February 2016, which includes identifying possible "red flags" and behaviours carers may look out for. An audit of care plans and risk assessments for evidence of carer involvement was also carried out and reported to the Leadership Forum.
Alice Dickenson
Historic (No Identified Response)
2016-0021 21 Jan 2016
Kent and Medway Cancer Collaborative
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The GP referral form for rapid access endoscopy is limited, potentially leading to the omission of critical past medical history that would assist endoscopists.
Julie Rose
Historic (No Identified Response)
14 Dec 2015
Kent and Medway NHS and Social Care Par…
Mental Health related deaths
Concerns summary (AI summary) The "Unable to Make Contact Protocol" lacks clarity on mandatory police welfare checks for high-risk patients, and staff demonstrated inadequate understanding of its procedures.
Kevin Gilbert
Historic (No Identified Response)
14 Dec 2015
St Thomas' Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was confusion and unreasonable delay in transferring an acute aortic dissection patient to a tertiary center, including a failure to escalate the transfer decision to a consultant.
Alan Ludlow
Historic (No Identified Response)
2015-0470 23 Nov 2015
Kent County Council
Other related deaths
Concerns summary (AI summary) Critical information about residents' past incidents and risks is not adequately exchanged between care providers during placement. This leads to new homes being unaware of vital safety history for vulnerable individuals.
Christine McNamara
All Responded
2015-0436 16 Nov 2015
Maidstone and Tunbridge Wells NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is a lack of clear pathways for post-ERCP patients with complications, and out-of-hours radiography is hampered by the absence of a Maidstone surgical consultant for urgent referrals.
Action Taken (AI summary) The trust implemented a new pathway in January 2016 for managing patients who develop post-endoscopic surgery complications, with a review scheduled for October 2016.