Kent and Medway
Coroner Area
Reports: 145
Earliest: Sep 2013
Latest: 24 Mar 2026
70% response rate (above 63% average).
Douglas Birch
All Responded
2015-0274
13 Jul 2015
HMP Swaleside
State Custody related deaths
Concerns summary (AI summary)
Prison officers were either unaware of or failed to follow instructions requiring them to elicit a response from prisoners upon cell unlocking. They also did not consistently receive or read crucial Prison Service Orders.
Action Taken
(AI summary)
HMP Swaleside issued a notice to staff on 10 August 2015 setting out local procedure for welfare checks and requiring staff to sign to confirm checks have taken place. NOMS is compiling a learning bulletin for all staff on their intranet by the end of September.
Patricia Holmes
All Responded
2015-0254
2 Jul 2015
East Kent Hospitals University NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The A&E doctor failed to recognize the serious risk of internal bleeding in a patient with multiple fractured ribs and on anticoagulation therapy, leading to inadequate action for their condition.
Action Taken
(AI summary)
East Kent University Hospitals NHS Trust has an approved algorithm in place to assess and treat patients with trauma and bleeding risk. A governor's order was issued at HMP Wayland on June 30, 2015, instructing staff to record medical issues in the wing observation book and the Local Security Strategy has been amended to reflect this procedure.
Deborah Roberts
Historic (No Identified Response)
11 Jun 2015
National Highways
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The Sheppey Road Bridge has a history of rear-end collisions due to its geometry affecting visibility and high speeds. Despite a safety review recommending a 50 mph limit, the speed limit remains 70 mph.
Robert Watt
Historic (No Identified Response)
2015-0145
17 Apr 2015
Medway NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Crucial information about clinic attendance and referrals was not communicated or documented. Junior doctors handled specialist consultations, and a urologist failed to review a patient with suspected malignancy and significant symptoms.
Kelly Willis
All Responded
2015-0122
30 Mar 2015
East Kent Hospitals University NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Failure to timely liaise with a tertiary care center regarding a patient's complex medical history and specific requests delayed critical investigations, missing opportunities to prevent deterioration.
Action Planned
(AI summary)
East Kent Hospitals will include an article in the "Risk Wise" publication reminding staff of the importance of reassessing and completing outstanding actions, and considering contacting tertiary treatment centers for guidance. They also highlight existing handover and review processes.
George Marks
All Responded
2015-0057
17 Feb 2015
Mayday Health Care Plc
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Agency staff demonstrated a fundamental lack of understanding regarding medication administration policies, prescription chart recording, patient nursing notes documentation, and correct handover procedures.
Action Taken
(AI summary)
Mayday Healthcare has implemented measures including monthly SMS reminders to staff, consultant training, client feedback forms, quarterly letters to staff, and updated yearly training program in regards to documentation, escalation, administration of medication and compassion.
Alex Kelly
All Responded
2014-0555
28 Dec 2014
HMP Cookham Wood
Medway Youth Offending Team
Ministry of Justice
+2 more
State Custody related deaths
Concerns summary (AI summary)
A vulnerable child was sentenced without forensic psychiatric assessment, and mental health support conflicted with disciplinary procedures, failing to adopt a holistic approach or consult outside agencies. A social worker allocation was also significantly delayed.
Action Taken
(AI summary)
Tower Hamlets Council details actions taken following a Serious Case Review, including maintaining social worker numbers and updating a protocol with the Youth Offending Service to clarify responsibilities when a young person receives a custodial sentence. They also highlight increased awareness among Social Work staff due to the Legal Aid, Sentencing and Punishment of Offenders Act 2012. Central and North West London NHS Trust (CNWL) describes its Health and Wellbeing Team's structure and processes, including mental health assessments and improved office space and IT access. They state that all clinical contact is recorded on Systm1, with line managers checking staff entries and annual record keeping audits to monitor documentation standards, and training provided to new team members for Systm1 use. Oxleas NHS Foundation Trust describes implementation of the CHAT tool for assessing new arrivals at HMPYOI Cookham Wood, with training and monitoring standards. They detail information governance training for staff and supervised medication dispensing procedures, including recording and reporting non-compliance. The Medway Youth Offending Service (YOT) describes actions taken in response to the coroner's concerns including ACCT training for the Resettlement Team, enhanced reviews overseen by a Governor, and submission of early release paperwork. They also detail procedures for initial planning meetings, maintaining contact, and final release meetings according to YJB National Standards. The Ministry of Justice outlines reforms in the Young People's Estate, including a standardised casework model, enhanced regimes, and changes to ACCT procedures. They detail night operating procedures and confirm that an information sharing protocol between relevant agencies at HMYOI Cookham Wood is being formulated.
Betty Smith
Historic (No Identified Response)
2014-0467
27 Oct 2014
East Kent Hospitals University NHS Foun…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient ITU bed capacity due to nursing shortages further compromises patient care.
Herbert Chandler
Historic (No Identified Response)
2014-0570
21 Aug 2014
East Kent Hospital University NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Multiple clinical management failures included inappropriate prescribing, delayed chest drain insertion, and poor communication of consultant findings. The Medical Registrar failed to conduct crucial pre-procedure checks, compounded by confusing medical records and absent consultant respiratory cover.
Joshua Brown
Partially Responded
2014-0289
17 Jul 2014
Care Quality Commission
Department of Health and Social Care
Kent and Medway NHS and Social Care Par…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The community health team lacked formal processes for family involvement and information sharing, especially when the patient withheld consent, hindering their ability to support him and verify information accuracy.
Noted
(AI summary)
The Department of Health references existing guidance regarding information sharing with family members and mental capacity assessments in cases of suicide risk, but does not outline any new action being taken.
Peter Franklin
All Responded
2014-0230
19 May 2014
Kent and Medway NHS and Social Care Par…
Maidstone and Tunbridge Wells NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. Significant delays in documentation meant the GP was unaware of crucial hospital admissions and mental health involvement.
Action Planned
(AI summary)
Kent and Medway NHS Trust has developed a joint action plan with Maidstone and Tunbridge Wells NHS Trust, extending Liaison Psychiatry service hours, introducing a recovery card for patients on discharge, and holding monthly meetings to review frequent presenters. Tunbridge Wells Hospital is implementing a SMART tool, working towards electronic discharge summaries by October 2014, holding frequent attenders' meetings, and adding a 3-hour Mental Capacity Act session to the junior doctor teaching program.
Winifred Dennis
All Responded
2014-0167
14 Apr 2014
Kent Community Health NHS Trust
Community health care and emergency services related deaths
Concerns summary (AI summary)
Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for specific equipment, not being communicated to new care homes.
Action Taken
(AI summary)
Kent Community Health NHS Trust has devised a formal process for transfer of care between community nursing teams. A working group has been established to revise policies and procedures, improve documentation and monitor through clinical audit. The training available to staff for holistic assessment and care planning has been revised and is being rolled out.
Nicos Michael
All Responded
2014-0168
14 Apr 2014
East Kent Hospitals University NHS Foun…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The coroner identified conflicting evidence regarding the deceased's recorded allergies, noting a lack of readily available and continuously updated allergy information for hospital staff, and that electronic prescribing was not compulsory.
Noted
(AI summary)
East Kent Hospitals University NHS Foundation Trust notes the coroner's concerns regarding the recording of a reported allergy to penicillin throughout the healthcare records, but states that concerns are based solely on the findings of the Root Cause Analysis undertaken into this case and the various statements provided by the staff involved in the care and treatment of Mr Michael.
William Winter
Historic (No Identified Response)
2014-0154
7 Apr 2014
East Kent Hospitals University NHS Foun…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Understaffing and unfamiliarity with escalation procedures on a Clinical Decisions Unit led to missed patient observations and delayed surgical review.
Lorna Cullen
Historic (No Identified Response)
2014-0105
11 Mar 2014
NHS Medway Clinical Commissioning Group
NHS Swale Clinical Commissioning Group
Other related deaths
Concerns summary (AI summary)
The coroner raised concerns about long-term liaison psychiatry nurse staffing levels covering hospital emergency departments, after evidence indicated patients needing mental health assessments were regularly waiting in excess of 2 hours due to staffing shortages.
Margaret Easterfield
Historic (No Identified Response)
2014-0091
3 Mar 2014
East Kent University Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.
Michael Longley
Historic (No Identified Response)
2013-0370
19 Dec 2013
Kent Community Health NHS Foundation Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral and written communication methods.
Keith Barton
All Responded
2013-0330
6 Dec 2013
Ashley Gardens Nursing Home
Care Home Health related deaths
Concerns summary (AI summary)
There was a lack of clarity in dysphagia supervision recommendations, insufficient training for all staff on dysphagia awareness, and a failure to complete incident reports, hindering further specialist reviews.
Action Taken
(AI summary)
Lifestyle Care booked dysphagia training for staff in February and March 2014 and a Nutrition and Hydration course in March 2014. They received confirmation from SALT that they will now be charging £125 per session and sessions can be booked from the end of March.
Dean Griffiths
Historic (No Identified Response)
2013-0299
14 Nov 2013
House of Commons
Other related deaths
Concerns summary (AI summary)
Insufficient time allocated for exercises created pressure, preventing Range Conducting Officers from completing crucial final assurance checks.
Ricky Anderson
Historic (No Identified Response)
2013-0227
9 Sep 2013
Kent and Medway NHS
Social Care Partnership Trust
Mental Health related deaths
Concerns summary (AI summary)
Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, and discharged a patient early without a care plan.