Kendray Hospital

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First report 4 Jul 2022•Latest report 4 Jul 2022

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Kendray Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. South Yorkshire (Western)

    AI-generated summary

    Ann Pickering · 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

    Ann Pickering developed throat-swelling and choking complaints, was diagnosed with severe anxiety and an eating disorder, and was admitted to Kendray Hospital under a section of the Mental Health Act. She later deteriorated physically, was transferred to Barnsley Hospital, and died there on 1 July 2021. The substantive concerns included delays in recognising and inserting an NG tube, delayed acceptance of her transfer by Barnsley Hospital, and a lack of clear transfer policies and procedures for patients under a section.

    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 Kendray Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in inserting required NG tubes

    Wider context from the report

    “During the inquest, evidence showed:- 1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. 2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer 3. Despite recognising an NG tube was required, one was not inserted until the 30.6.21 4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. ”
    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 Kendray Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clear procedures for transferring patients under a section

    Wider context from the report

    “During the inquest, evidence showed:- 1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. 2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer 3. Despite recognising an NG tube was required, one was not inserted until the 30.6.21 4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. ”
    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 Kendray Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clear procedures for documentation and resources accompanying transferred patients

    Wider context from the report

    “During the inquest, evidence showed:- 1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. 2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer 3. Despite recognising an NG tube was required, one was not inserted until the 30.6.21 4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. ”
    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 Kendray Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in accepting transfers of patients under a section

    Wider context from the report

    “During the inquest, evidence showed:- 1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. 2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer 3. Despite recognising an NG tube was required, one was not inserted until the 30.6.21 4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. ”
    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

Data last updated 7 September 2026