Recipient

Dartford and Gravesham NHS Trust

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First report 20 Apr 2017•Latest report 4 Mar 2024

Recipient record

Reports, concerns and published responses

Health and care · NHS trust. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
2

Naming this recipient

Published responses
50%

Found for named reports

Concerns addressed
3

Across all linked responses

Stated actions
10

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

50%published responses found
10stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Dartford and Gravesham NHS Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Mid Kent and Medway

    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.

    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 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

    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
    Page 2 · response
    Published 14 March 2024

    Open published response

    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
    Page 2 · response
    Published 14 March 2024

    Open published response

    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
    Page 2 · response
    Published 14 March 2024

    Open published response

    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
    Page 2 · response
    Published 14 March 2024

    Open published response

    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
    Page 2 · response
    Published 14 March 2024

    Open published response

    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
    Page 1 · response
    Published 14 March 2024

    Open published response

  2. North West Kent

    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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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

50%
50%All other recipients 58%
0%100%

How actions were described at the time

This respondent
20%10%10%60%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026