4 Mar 2024 Sarah Rhiannon Keen · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 3 Failure to provide carers with relevant patient risks and care information View source Failure to document and communicate discharge medication recommendations View source Use of clinical abbreviations not universally understood by the medical team View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Speak with supported accommodation staff about patients’ medication and available discharge support, considering information sharing without consent where self-harm risk is significant.
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Action
State in discharge notifications when medication has been reduced and record the reason.
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Action
Record when a reduced medication quantity should be prescribed because of self-harm or overdose risk.
View source
Action
Record handovers between nursing staff and residence staff when escorting patients to their place of residence.
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Action
Circulate a Trust-wide reminder to both organisations about avoiding or spelling out abbreviations in patient records.
View source
Action
Record handovers to enhanced care nurses, including the risks of harm if they are not present.
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AI-generated summary
Sarah Rhiannon Keen · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sarah Keen, who had a history of mental health difficulties and required support with daily activities, died after being discharged from hospital to supported accommodation. A post-mortem examination determined the medical cause of death to be multi-drug toxicity involving fluoxetine and dihydrocodeine in the presence of cocaine. The principal concerns were inadequate communication to carers about her risks and medication, insufficient guidance about discharge medication, and use of an abbreviation that was not universally understood.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dartford and Gravesham NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide carers with relevant patient risks and care information
Wider context from the report “(1) The enhanced carer had not been told the reason that she was providing one to one care for Sarah, was not aware of any issues in relation to mental health, the fact of the deprivation of liberty order, or that Sarah was a risk of deliberate self harm including by overdosing on prescribed medications. She was not aware that Sarah had been discharged with seven days of medication or that her medication was being held on her behalf by another in the community. Although it was unusual for her to accompany a person with capacity to their address it was not unusual for her to accompany those without capacity. As a consequence the support worker who was on duty at the time that Sarah returned to her accommodation was not aware from an independent source that Sarah had been discharged with seven days of medication, Sarah lied to the support worker when she was asked whether she had been given any medication disclosing only the fact that she had been given ferrous sulphate which she handed over when her bag contained seven days of the medication which she subsequently ingested with fatal results. Even recognising medical confidentiality, those with a caring role who have not been provided with relevant information cannot meet the needs of the patient if they do not know what the risks are or know when it is appropriate to bring information to another professional charged with the care of the patient be it a nurse, doctor or support worker
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dartford and Gravesham NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document and communicate discharge medication recommendations
Wider context from the report “(2) The note left by the psychiatrist on the medical records did not contain any recommendations as to medication. The psychiatrist was aware that Sarah’s medication was being held by her support workers as a result of the risk of mismanagement by overdosing. He was also aware that it was policy for the hospital to dispense 14 days of medication on discharge. He did not consider asking the discharging doctor to not provide Sarah with any medication on the basis that there was already a prescription in the community and although he considered that it was appropriate for the quantity of discharge medication to be reduced to seven days to reduce the risk of overdose, he did not communicate this to the medical team within the note.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dartford and Gravesham NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Use of clinical abbreviations not universally understood by the medical team
Wider context from the report “(3) The note left by the psychiatrist on the medical records contained the abbreviation DSH. It was clear from the evidence given at the inquest that this was not universally understood by the medical team to refer to deliberate self harm .
Although the Trust has taken some action following the evidence being given at the inquest in that the psychiatrist after giving evidence sent an e-mail to his team detailing his reflections i.eam to request that consideration be given to a number of matters in dealing with patients at the hospital. Having considered the e-mail I did not regard this as meeting the extent of my concerns
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Speak with supported accommodation staff about patients’ medication and available discharge support, considering information sharing without consent where self-harm risk is significant.
Verbatim wording from the response “• If patients are living in supported or hostel accommodation, staff should make every effort to speak with supporting staff in relation to medication, and support available to the patient on discharge. This would preferably be done with the patient’s consent, but if the risk to self-harm is significant, must be considered without consent of the patient.” Source location Response from Darent Valley Trust and Kent & Medway NHS and Social Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation State in discharge notifications when medication has been reduced and record the reason.
Verbatim wording from the response “• The discharge notification should indicate that a reduced amount of medication has been prescribed and the reason for this recorded.” Source location Response from Darent Valley Trust and Kent & Medway NHS and Social Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record when a reduced medication quantity should be prescribed because of self-harm or overdose risk.
Verbatim wording from the response “• The discharging clinician (both or either DGT and KMPT) should record if a reduced amount of medication should be prescribed because of risk of self-harm or overdose.” Source location Response from Darent Valley Trust and Kent & Medway NHS and Social Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record handovers between nursing staff and residence staff when escorting patients to their place of residence.
Verbatim wording from the response “• If a member of staff is required to escort a patient to their place of residence, the receiving person is informed and a handover between nursing staff and residence staff occurs. A note of this handover will be recorded in the patient record when the member of staff returns to the ward.” Source location Response from Darent Valley Trust and Kent & Medway NHS and Social Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate a Trust-wide reminder to both organisations about avoiding or spelling out abbreviations in patient records.
Verbatim wording from the response “1. A reminder to staff in both organisations has been circulated through Trust wide communications in regard to the use of abbreviations in patient records.” Source location Response from Darent Valley Trust and Kent & Medway NHS and Social Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record handovers to enhanced care nurses, including the risks of harm if they are not present.
Verbatim wording from the response “• Staff should record their handover to the enhanced care nurse to explain the risks to harm if they are not present.” Source location Response from Darent Valley Trust and Kent & Medway NHS and Social Partnership
Open published response
20 Apr 2017 Sian Marie Hollands · Prevention of Future Deaths report North West Kent
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Concerns raised 4 Failure to correctly diagnose pulmonary embolism View source Failure to provide doctors with nurses' medical notes View source Deficiencies in operation of PAR scoring (now NEWS) View source Deficiencies in training of nurses and doctors View source See 1 more concern
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sian Marie Hollands · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sian Hollands attended Darent Valley Hospital on 14 November 2015 with breathlessness and chest pain after recent surgery and possible opiate withdrawal. She was later suspected to have a pulmonary embolus, suffered a cardiac arrest, and died on 15 November 2015. The stated concerns included PAR scoring and staff training, doctors not being provided with nurses’ medical notes, and failure to correctly diagnose pulmonary embolism.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dartford and Gravesham NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly diagnose pulmonary embolism
Wider context from the report “(3) The failure of doctors to correctly diagnose pulmonary embolism
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dartford and Gravesham NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide doctors with nurses' medical notes
Wider context from the report “(2) The failure of doctors to be provided with nurses medical notes
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dartford and Gravesham NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in operation of PAR scoring (now NEWS)
Wider context from the report “(1) The operating of the PAR scoring (now NEWS) and training of nurses and doctors
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dartford and Gravesham NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in training of nurses and doctors
Wider context from the report “(1) The operating of the PAR scoring (now NEWS) and training of nurses and doctors
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations