Recipient

Kent Community Health NHS Foundation Trust

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First report 19 Dec 2013•Latest report 14 Apr 2014

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
1

Across all linked responses

Stated actions
5

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
5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Kent Community Health NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. North East Kent

    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.

    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 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

    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
    Page 1 · response
    Published 14 April 2014

    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

    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
    Page 1 · response
    Published 14 April 2014

    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

    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
    Page 1 · response
    Published 14 April 2014

    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

    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
    Page 1 · response
    Published 14 April 2014

    Open published response

  2. Central and South East Kent

    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.

    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 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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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%60%20%
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