14 Apr 2014 Winifred Olive DENNIS · Prevention of Future Deaths report North East Kent
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Concerns raised 1 Lack of formal handover and transfer of important information between community nursing teams 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. 4
Action
Monitor transfer-of-care arrangements through clinical audit and Trust committee structures.
View source
Action
Improve transfer documentation so patients receive holistic reassessment and clearly documented care needs before transfer.
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Action
Revise transfer-of-care policies and procedures through an established working group.
View source
Action
Implement a formal process for transferring care between community nursing teams.
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AI-generated summary
Winifred Olive DENNIS · 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
Winifred Olive DENNIS died at home on 27 December 2012 after a deterioration in health leading to reduced and ultimately no mobility. She had developed a deep sacral pressure sore, and the inquest recorded bronchopneumonia and the pressure sore as the clinical causes of death. The report identified a concern that information about her previous airflow mattress was not formally handed over when she moved between care settings, potentially reducing the provision of optimum care.
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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 Kent Community Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal handover and transfer of important information between community nursing teams
Wider context from the report “(1) The evidence was that within Kent Community Health NHS Trust the community nurses are organised into teams dependent upon the GP surgeries that they are covering. As a result, the moving of a patient from her own home to a Care Home, or between Care Homes, can cause her to be transferred from one Community Nursing Team to another, occurred in this instance. Although from the patient's notes would be transfer, the Trust had no formal handover document as such for a patient in these circumstances , and in this instance, the information that at her previous Home she had had the benefit of an airflow mattress was not communicated to the next Home on her move there . Care Homes look to the community nurses for such guidance.
(2) In other cases, similar important information not directly of a clinical nature might not be transferred and the chances of optimum care being delivered to a patient might accordingly be reduced.
” 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 Monitor transfer-of-care arrangements through clinical audit and Trust committee structures.
Verbatim wording from the response “Response
A formal process to enable the transfer of care between community nursing teams has been devised. A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care. Work is already underway to improve the documentation associated with transfer to ensure all patients have a full holistic reassessment prior to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care. This process ensures continuity of care. Patients’ on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to staff for holistic assessment and care planning has been revised and the new programme is now being rolled out.” Source location 2014-0167-Response-by-Kent-Community-Health-NHS-Trust
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 Improve transfer documentation so patients receive holistic reassessment and clearly documented care needs before transfer.
Verbatim wording from the response “Response
A formal process to enable the transfer of care between community nursing teams has been devised. A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care. Work is already underway to improve the documentation associated with transfer to ensure all patients have a full holistic reassessment prior to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care. This process ensures continuity of care. Patients’ on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to staff for holistic assessment and care planning has been revised and the new programme is now being rolled out.” Source location 2014-0167-Response-by-Kent-Community-Health-NHS-Trust
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 Revise transfer-of-care policies and procedures through an established working group.
Verbatim wording from the response “Response
A formal process to enable the transfer of care between community nursing teams has been devised. A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care. Work is already underway to improve the documentation associated with transfer to ensure all patients have a full holistic reassessment prior to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care. This process ensures continuity of care. Patients’ on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to staff for holistic assessment and care planning has been revised and the new programme is now being rolled out.” Source location 2014-0167-Response-by-Kent-Community-Health-NHS-Trust
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 Implement a formal process for transferring care between community nursing teams.
Verbatim wording from the response “Response
A formal process to enable the transfer of care between community nursing teams has been devised. A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care. Work is already underway to improve the documentation associated with transfer to ensure all patients have a full holistic reassessment prior to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care. This process ensures continuity of care. Patients’ on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to staff for holistic assessment and care planning has been revised and the new programme is now being rolled out.” Source location 2014-0167-Response-by-Kent-Community-Health-NHS-Trust
Open published response
Concerns raised 1 Failure of effective oral and written communication between integrated care and district nursing services View source
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
Michael Longley · 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
Michael Longley had an adverse reaction to Rivaroxaban administered after hip surgery. He was admitted to hospital with an unrecordable platelet count and died the same day; the report also identified difficulties in communication between Integrated Care 24 and the District Nursing Service.
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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 Kent Community Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of effective oral and written communication between integrated care and district nursing services
Wider context from the report “I heard evidence that Integrated Care 24 had difficulties in contacted the District Nursing Service on 25th December 2011 and I consider that improved methods of both oral and written communication between IC24 and the district nurses must be put in place .
” 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