10 Feb 2026 Barbara Wingate · Prevention of Future Deaths report Kent and Medway
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Concerns raised 1 Failure to provide timely appropriate community care packages or alternative placements for medically fit patients View source
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AI-generated summary
Barbara Wingate · 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
Barbara Wingate, a 71-year-old woman, fell at home on 18 May 2025, sustained multiple pelvic fractures, suffered a cardiac arrest and died on 21 May 2025 following multiple organ failure. The inquest identified avoidable delays in diagnosing and treating her pelvic fractures. The report also raised concerns about emergency department capacity, delayed discharge of medically fit patients, and insufficient timely community care or alternative placements, creating risks for other critically ill patients.
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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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely appropriate community care packages or alternative placements for medically fit patients
Wider context from the report “Evidence heard at the inquest revealed that the resuscitation department where Mrs Wingate should have been admitted was full and the evidence indicated that this was and is almost a daily occurrence at the Trust . The court heard that the main issue is trying to discharge a patient to a suitable area in the hospital to free up a cubicle or bay in the resuscitation department. This in turn is due to beds being occupied by patients who are medically fit to be discharged . On any given day the court heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital.
The court heard that the main delay is in discharging patients to appropriate settings or placements and the Trust have taken all steps they can internally to improve the flow of patients through the hospital. From the evidence it would appear that those responsible for providing care in the community including both the social care providers and the community healthcare providers are not providing either timely appropriate care packages in the patient's home or a bed in an alternative placement be that a nursing home or residential home placement . The evidence suggested that where patients were self funding the delays in discharge were less acute.
This means patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illnesses themselves which could lead to their own death but are also blocking beds which are needed to treat patients who require acute care . This is leading to patients being kept longer in the emergency department and reducing available space to receive new critically ill patients . Both of these options can lead to death as seen in this case and there is clearly a risk of death for others requiring clinical care in an acute hospital.
” 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 Work with the trust to identify themes and trends causing hospital-discharge delays.
Verbatim wording from the response “Despite the improvements made to the length of stay for people with No Criteria to Reside attributable to KCC, our data clearly shows that 50% of referrals experience delays beyond the control of KCC. The main reasons for these delays are availability of discharge documentation, medication, and transport availability. These delays are reported in Medway Hospital’s No” Source location Response from Kent County Council
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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 Review the commissioning of hospital-discharge services.
Verbatim wording from the response “KCC continues to review hospital discharge practice and guidance in collaboration with system partners. The local authority is currently undergoing a review of the Short Term Pathways practice and processes, and the commissioning of hospital discharge services. KCC will continue to focus on the principles of Discharge to Assess and home first with the ambition of further increasing timely discharges into Pathway 1 home-based services.” Source location Response from Kent County Council
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 Recruit staff and improve referral processes to reduce Kent Enablement at Home discharge times.
Verbatim wording from the response “During this period Kent Enablement at Home were experiencing a high number of vacancies within the team, with a 30% vacancy factor which impacted on the referral to discharge time. A recruitment campaign and efficiencies created within referral processes has reduced this time to 1.8 days. This has been consistent for the last three months and is in line with key performance indicators set by Medway Hospital of a 48 hour timescale for discharge back to a person’s own home.” Source location Response from Kent County Council
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 Review Short Term Pathways practice and processes.
Verbatim wording from the response “KCC continues to review hospital discharge practice and guidance in collaboration with system partners. The local authority is currently undergoing a review of the Short Term Pathways practice and processes, and the commissioning of hospital discharge services. KCC will continue to focus on the principles of Discharge to Assess and home first with the ambition of further increasing timely discharges into Pathway 1 home-based services.” Source location Response from Kent County Council
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 referral processes for the short-term pathway to reduce transfer-of-care times.
Verbatim wording from the response “A small number of people are discharged to a short-term bed where they receive a period of enablement and/or assessment of their longer-term care and support needs. The majority of these people are discharged to KCC’s Adult Short Stay Services which are in-house enablement beds. During the time that Mrs Wingate died, the average time for discharge to be facilitated from the time of referral to the Short-Term Pathways team was 5.3 days. Improvements have been made to the referral processes for this pathway, and the current average transfer of care time is 3 days.” Source location Response from Kent County Council
Open published response
10 Feb 2026 Liam Andrew SUTTON · Prevention of Future Deaths report Kent and Medway
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Concerns raised 2 Delays in arranging timely appropriate community care packages or alternative placements for medically fit patients View source Failure to transfer patients from the emergency resuscitation area to suitable higher-acuity beds in a timely manner View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Liam Andrew SUTTON · 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
Liam Sutton became unconscious at home after discharge following a total knee replacement with increased opioid medication, and was subsequently treated for suspected opioid toxicity, pneumonia or sepsis, respiratory complications and acute kidney injury. After intensive care treatment involving ventilation and repeated extubation attempts, he suffered an unresuscitable cardiac arrest during reintubation and died. The principal concerns were prolonged occupancy of the emergency department resuscitation area and hospital bed-blocking linked to delays in discharge and access to appropriate community or care placements.
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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 County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in arranging timely appropriate community care packages or alternative placements for medically fit patients
Wider context from the report “The court heard in the inquest revealed that the resuscitation department where Mr Sutton was admitted was busy and the evidence indicated that this was and is almost a daily occurrence at the Trust. Mr Sutton remained in the Emergency department resuscitation area for longer than 24 hours and should instead have been transferred to a suitable bed in the hospital. The Intensivist who gave evidence was clear that he should have been transferred to the High Dependency/ Intensive Care department and that patients who are admitted in a timely manner have a much better chance of survival. This also means that bays in the resuscitation department are not free to admit or attend to new acutely ill patients arriving at the hospital.
The court heard that the main issue is trying to discharge a patient to a suitable area in the hospital to free up a cubicle or bay in the resuscitation department. This in turn is due to beds being occupied by patients who are medically fit to be discharged . On any given day we heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital .
The court heard that the main delay is in discharging patients to appropriate settings or placements and the Trust have taken all steps they can internally to improve the flow of patients through the hospital. From the evidence the court heard it would appear that those responsible for providing care in the community including both the social care providers and the community healthcare providers are not providing either timely appropriate care packages in the patient's home or a bed in an alternative placement be that a nursing home or residential home placement . The evidence suggested that where patients were self funding the delays in discharge were less acute.
This means patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illnesses themselves which could lead to their own death but are also blocking beds which are needed to treat patients who require acute care in a suitable setting. This is leading to patients being kept longer in the emergency department and reducing available space to receive new critically ill patients. Both of these options can lead to death and there is clearly a risk of death for others requiring clinical care in an acute hospital
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer patients from the emergency resuscitation area to suitable higher-acuity beds in a timely manner
Wider context from the report “The court heard in the inquest revealed that the resuscitation department where Mr Sutton was admitted was busy and the evidence indicated that this was and is almost a daily occurrence at the Trust. Mr Sutton remained in the Emergency department resuscitation area for longer than 24 hours and should instead have been transferred to a suitable bed in the hospital . The Intensivist who gave evidence was clear that he should have been transferred to the High Dependency/ Intensive Care department and that patients who are admitted in a timely manner have a much better chance of survival . This also means that bays in the resuscitation department are not free to admit or attend to new acutely ill patients arriving at the hospital.
The court heard that the main issue is trying to discharge a patient to a suitable area in the hospital to free up a cubicle or bay in the resuscitation department. This in turn is due to beds being occupied by patients who are medically fit to be discharged. On any given day we heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital.
The court heard that the main delay is in discharging patients to appropriate settings or placements and the Trust have taken all steps they can internally to improve the flow of patients through the hospital. From the evidence the court heard it would appear that those responsible for providing care in the community including both the social care providers and the community healthcare providers are not providing either timely appropriate care packages in the patient's home or a bed in an alternative placement be that a nursing home or residential home placement. The evidence suggested that where patients were self funding the delays in discharge were less acute.
This means patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illnesses themselves which could lead to their own death but are also blocking beds which are needed to treat patients who require acute care in a suitable setting. This is leading to patients being kept longer in the emergency department and reducing available space to receive new critically ill patients. Both of these options can lead to death and there is clearly a risk of death for others requiring clinical care in an acute hospital
” 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 Improve Kent Enablement at Home referral processes to reduce time from discharge referral to home-care support.
Verbatim wording from the response “During this period, the team was running with a 20% vacancy factor. The vacancy factor combined with the increase in demand led to an increase in the time from referral to discharge for these people which was an average of 3.8 days during the week that Mr Sutton died. A recruitment campaign and efficiencies created within Kent Enablement at Home’s referral processes has reduced the timescale for people discharged with home care support to 1.8 days. This has been consistent for the last three months and is in line with key performance indicators set by Medway Hospital of a 48-hour timescale for discharge back to a person’s own home.” Source location Response from Kent County Council
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 referral processes for short-term bed pathways to reduce transfer-of-care times.
Verbatim wording from the response “A small number of people are discharged to a short-term bed where they receive a period of enablement and/or assessment of their longer-term care and support needs. The majority of these people are discharged to KCC’s Adult Short Stay Services which are in-house enablement beds. During the month of December 2024 when Mr Sutton died, KCC identified one person who required support from this pathway and the time for discharge to be facilitated from the time of referral was 6 days. Since the time of Mr Sutton’s death, improvements have been made to the referral processes for this pathway, and the current average transfer of care time is 3 days.” Source location Response from Kent County Council
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 Complete recruitment activity to increase Short Term Pathways Team capacity and reduce discharge delays.
Verbatim wording from the response “During this period, the team was running with a 20% vacancy factor. The vacancy factor combined with the increase in demand led to an increase in the time from referral to discharge for these people which was an average of 3.8 days during the week that Mr Sutton died. A recruitment campaign and efficiencies created within Kent Enablement at Home’s referral processes has reduced the timescale for people discharged with home care support to 1.8 days. This has been consistent for the last three months and is in line with key performance indicators set by Medway Hospital of a 48-hour timescale for discharge back to a person’s own home.” Source location Response from Kent County Council
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 Review the commissioning of hospital discharge services.
Verbatim wording from the response “KCC continues to review hospital discharge practice and guidance in collaboration with system partners. The local authority is currently undergoing a review of the Short-Term Pathways practice and processes, and the commissioning of hospital discharge services. KCC will continue to focus on the principles of Discharge to Assess and home first with the ambition of further increasing timely discharges into Pathway 1 home-based services.” Source location Response from Kent County Council
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 Review Short-Term Pathways practices and processes.
Verbatim wording from the response “KCC continues to review hospital discharge practice and guidance in collaboration with system partners. The local authority is currently undergoing a review of the Short-Term Pathways practice and processes, and the commissioning of hospital discharge services. KCC will continue to focus on the principles of Discharge to Assess and home first with the ambition of further increasing timely discharges into Pathway 1 home-based services.” Source location Response from Kent County Council
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 Work with the hospital trust to identify themes and trends causing delays in hospital discharge.
Verbatim wording from the response “transport availability. These delays are reported in Medway Hospital’s No Criteria to Reside report and KCC continue to work with the trust in identifying themes and trends that delay hospital discharge.” Source location Response from Kent County Council
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 Continue applying Discharge to Assess and home-first principles to support timely discharge into home-based services.
Verbatim wording from the response “At the time of Mr Sutton’s death, KCC operated a Discharge to Assess model and home first approach in line with national statutory discharge guidance, Hospital discharge and community support guidance - GOV.UK. The Local Authority continues to operate this model.” Source location Response from Kent County Council
Open published response
18 Oct 2022 Max TURBUTT · Prevention of Future Deaths report Inner North London
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Concerns raised 2 Failure to provide an accessible alternative contact when a personal advisor or social worker is unavailable View source Failure of the crisis number to provide a responsive service View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Max TURBUTT · 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
Max Turbutt had experienced mental ill health for several years and had been supported by Kent County Council services as a care leaver. The report states that he died by suicide, with the medical cause of death recorded as hanging. Concerns were raised that attempts by Max and his father to contact his personal adviser were unsuccessful, with no phone redirect or email out-of-office message, and that a crisis number led only to an answerphone.
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an accessible alternative contact when a personal advisor or social worker is unavailable
Wider context from the report “Max’s father told me at inquest that in March and April 2022, Max tried to contact his personal advisor at the 18+ Service at Thistley Hill in Dover on several occasions over a number of weeks, but found her phone always to be switched off. There was no redirect and no out of office on her email.
Max’s father also tried to call her, with the same result. Just over a week after Max’s death, his family received a letter addressed to him from Kent Social Services, explaining that his social worker was off sick . A crisis number was given and Mr Turbutt called it, but it was simply an answerphone.
This arrangement does not seem adequate for a vulnerable person in need.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the crisis number to provide a responsive service
Wider context from the report “Max’s father told me at inquest that in March and April 2022, Max tried to contact his personal advisor at the 18+ Service at Thistley Hill in Dover on several occasions over a number of weeks, but found her phone always to be switched off. There was no redirect and no out of office on her email.
Max’s father also tried to call her, with the same result. Just over a week after Max’s death, his family received a letter addressed to him from Kent Social Services, explaining that his social worker was off sick. A crisis number was given and Mr Turbutt called it, but it was simply an answerphone.
This arrangement does not seem adequate for a vulnerable person in need.
” 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 Advise young adults immediately when their allocated Personal Advisor is off long-term sick, providing the Team Manager’s name and Duty contact number.
Verbatim wording from the response “In direct response to the concerns you raised, when a tragic event happens, our service reviews any learning and on investigation of the concerns raised, whilst there was only a very short period of time between the Personal Advisor going off unwell and Max’s death, the service has made the following changes:” Source location Response from Kent County Council
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 Require the relevant staff member to add a mobile-phone voice message identifying whom to contact during their absence.
Verbatim wording from the response “In direct response to the concerns you raised, when a tragic event happens, our service reviews any learning and on investigation of the concerns raised, whilst there was only a very short period of time between the Personal Advisor going off unwell and Max’s death, the service has made the following changes:” Source location Response from Kent County Council
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 Ensure an out-of-office email reply is added when a staff member is absent on a long-term basis.
Verbatim wording from the response “In direct response to the concerns you raised, when a tragic event happens, our service reviews any learning and on investigation of the concerns raised, whilst there was only a very short period of time between the Personal Advisor going off unwell and Max’s death, the service has made the following changes:” Source location Response from Kent County Council
Open published response
12 May 2022 Pauline Keen · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 1 Lack of a policy governing communication between KMPT and the Kent County Council AMHP service to ensure timely Mental Health Act applications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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
Pauline 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
Pauline Keen fell at home in January 2021, sustained an acetabular fracture, and was later transferred to Harrier Lodge Care Home after hospital admission. Her mental health deteriorated, and although assessment under the Mental Health Act concluded that she should be admitted, there was a failure to ensure that the application was made without delay amid uncertainty over bed communication responsibilities. She died on 24 April 2021 from multiorgan failure, sepsis and bronchopneumonia.
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy governing communication between KMPT and the Kent County Council AMHP service to ensure timely Mental Health Act applications
Wider context from the report “(1) There is no policy in place between KMPT and Kent County Council AMHP service as to how the organisations communicate with one another to ensure that applications under the Mental Health Act are made as soon as reasonably practicable without delay to patients .
” Open source report
11 Aug 2021 Hadley John Savory · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 8 Lack of clear information-sharing arrangements for service users with potentially fluctuating mental capacity View source Failure to record attempts to escalate internal disagreements over team allocation View source Failure to develop care and support plans for people assessed as having eligible needs View source Failure to ensure eligible Care Act needs are met during transfers between services View source Lack of multi-agency procedures for safe discharge of patients with concurrent care needs View source Lack of recording arrangements for internal disagreements over case allocation View source Failure to hold multi-agency discharge planning meetings View source Lack of clarity about the relationship between Care Act safeguarding duties and self-neglect or hoarding procedures View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Hadley John Savory · 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
Hadley John Savory was discharged from hospital on 25 September 2019 without evidence of a multi-agency planning meeting, and his care, support and treatment plan was unclear. His presentation later declined in the community, safeguarding referrals did not lead to multi-agency meetings, and he was found dead at home on 13 December 2019; toxicological evidence indicated that he had taken a lethal dose of methadone. The principal concerns related to hospital discharge planning, allocation of care responsibilities, meeting eligible care needs, safeguarding procedures for self-neglect or hoarding, and information sharing where mental capacity may fluctuate.
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear information-sharing arrangements for service users with potentially fluctuating mental capacity
Wider context from the report “(5) It was unclear as to how information sharing operated in respect of service users who are identified as potentially having fluctuating mental capacity in respect of their care and support needs .
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record attempts to escalate internal disagreements over team allocation
Wider context from the report “(2) There was no recording (or available evidence of recording) of attempts to escalate internal disagreements as to which team Mr Savory should have been allocated to . Nor did the evidence establish how internal disagreements as to allocation of cases were recorded;
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to develop care and support plans for people assessed as having eligible needs
Wider context from the report “(3) The evidence was not clear as to how eligible care needs under the Care Act are met when a service user is transferring between services. In Mr Savory’s case he was assessed as having eligible needs but no care and support plan was developed ;
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure eligible Care Act needs are met during transfers between services
Wider context from the report “(3) The evidence was not clear as to how eligible care needs under the Care Act are met when a service user is transferring between services . In Mr Savory’s case he was assessed as having eligible needs but no care and support plan was developed;
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of multi-agency procedures for safe discharge of patients with concurrent care needs
Wider context from the report “(1) There was no evidence of a multi Agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs ;
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of recording arrangements for internal disagreements over case allocation
Wider context from the report “(2) There was no recording (or available evidence of recording) of attempts to escalate internal disagreements as to which team Mr Savory should have been allocated to. Nor did the evidence establish how internal disagreements as to allocation of cases were recorded ;
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to hold multi-agency discharge planning meetings
Wider context from the report “(1) There was no evidence of a multi Agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019 . Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs;
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the relationship between Care Act safeguarding duties and self-neglect or hoarding procedures
Wider context from the report “(4) The evidence demonstrated that there was a lack of clarity as to the interrelationship between safeguarding duties under the Care Act and the operation of the Kent and Medway Multi-Agency Policy and Procedures to Support People that Self-Neglect or Demonstrate Hoarding Behaviour ;
” 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 Identify patients requiring social care support through multidisciplinary teams and accept referrals using the Ready to Transfer form.
Verbatim wording from the response “People/patients who require social care support/assessment will be identified at the MDTs and accepted as a referral via the Ready to Transfer (RTT) form. This new policy helps to ensure that individual’s needs are identified and considered pre and post discharge from hospital to ensure that physical and social needs are factored in within the discharge process.” Source location Response-from-Kent-County-Council
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 Establish named KCC hospital discharge leads to attend discharge management meetings and provide social care advice, guidance and escalation.
Verbatim wording from the response “There will be named leads for each Acute and Community Hospital which will be the KCC Short Term Pathways (STP) Team Manager, supported by the Senior Practitioner and Social Care Discharge Co-Ordinator in the first instance with escalation if required to the area Service Manager within STP. The expectation is that these named leads will attend discharge management meetings and together with health colleagues will provide social care advice and information, guidance as well as influencing and supporting the decision making process of the Multi-Disciplinary Teams (MDTs) for safe discharges of people via Discharge to Assess.” Source location Response-from-Kent-County-Council
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 Brief Adult Social Care staff on the updated self-neglect and hoarding policy and its revised risk categories, duties and procedures.
Verbatim wording from the response “Kent and Medway Safeguarding Adults Board have recently published their updated ‘Policy and Procedures to Support People that Self-Neglect or Demonstrate Hoarding Behaviour’. Following this update, a briefing was sent to all Adult Social Care staff on 6th October 2022 and the changes were highlighted within that communication.” Source location Response-from-Kent-County-Council
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 Continue participating in the Kent and Medway Information Partnership to support lawful, safe and secure information sharing.
Verbatim wording from the response “Information sharing should be more robust under these new/revised policies and procedures. In addition, KCC remain committed to appropriate information sharing by continuing to be a signatory on the Kent and Medway Information Partnership, which promotes openness and transparency in information sharing, as well as appropriate governance and support, which assists us to share personal information lawfully, safely, and securely.” Source location Response-from-Kent-County-Council
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 Update the hospital discharge policy and operating model, supported by discharge guidance action cards defining responsibilities for key roles.
Verbatim wording from the response “Following the sad death of Mr Savory and due to changes to practice following COVID, KCC updated its ‘Hospital Discharge Service Policy and Operating Model’. This new policy and operating model is designed to support the full implementation of discharge, and to aide this a set of discharge guidance action cards has been developed to summarise responsibilities for key roles within the hospital discharge process.” Source location Response-from-Kent-County-Council
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 Deliver self-neglect awareness activities through specialist training, e-learning, practitioner events, safeguarding-review briefings and Care Act briefings.
Verbatim wording from the response “KCC has also continued to undertake activities to raise practitioners’ awareness around the important subject of self-neglect and the importance of acting appropriately in response. These have included:” Source location Response-from-Kent-County-Council
Open published response
3 Feb 2021 CHRISTOPHER SMITH · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 13 Unsafe and unhygienic home conditions, including leaks and exposed electrical wiring View source Failure to complete recommended home assessments before discharge View source Failure to make district nurse referrals for specialist wound care View source Failure to reassess fluctuating mental capacity View source Failure to verify community care arrangements at discharge View source Failure to act on safeguarding alerts View source Failure to inform families of discharge home when care is required View source Incomplete and inaccurate discharge nursing documentation View source Absence of a bed in the home View source Incorrect recording of next-of-kin information in medical records View source Failure to respond appropriately to deterioration while patients remain on discharge wards View source Failure to establish capacity before decisions about care and treatment View source Failure to provide dietary requirements adequate for patients’ needs View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
CHRISTOPHER SMITH · 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
Christopher Smith was admitted to hospital with peripheral vascular disease, extensive leg ulcers, epilepsy and infections, and died on 4 March 2019 after deterioration following discharge home. Principal concerns included inadequate discharge planning and capacity reassessment, failure to arrange home and district nursing support, unsafe home conditions and an unacted-on safeguarding alert, and inadequate nutritional 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 County Council; that does not assign responsibility.
PFD Monitor interpretation Unsafe and unhygienic home conditions, including leaks and exposed electrical wiring
Wider context from the report “(6) Transport staff returning Mr Smith home found he had no key. One was located and on entering the property found conditions that caused them serious concern about the hygiene and health and safety within the property with a leak, uncleanliness and exposed electrical wiring and that there was no bed.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to complete recommended home assessments before discharge
Wider context from the report “(1) A recommended home assessment was not completed as part of Mr Smith’s planned discharge from hospital.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make district nurse referrals for specialist wound care
Wider context from the report “(5) Mr Smith has extensive leg ulcers that required specialist input. No district nurse referral was made to ensure that Mr Smith’s leg ulcers were treated.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess fluctuating mental capacity
Wider context from the report “(3) Mr Smith remained on a discharge ward from 2nd February until his discharge on 10th February even though he suffered a deterioration in his medical condition. Mr Smith’s capacity fluctuated during his admission, he was noted by nurses to be confused and his capacity was not reassessed .
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to verify community care arrangements at discharge
Wider context from the report “(4) Nursing notes in respect of Mr Smith’s discharge were incomplete, incorrect, and led to assumptions being made that Mr Smith
a. had capacity to make decisions about his care and treatment
b. was being cared for in the community .
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to act on safeguarding alerts
Wider context from the report “(7) Transport staff were informed by the hospital not to return Mr Smith to the hospital as there was no bed available and they therefore raised a safeguarding alert. The safeguarding alert was not acted upon and Mr Smith was found by family after five days lying on the floor of his home with no dressing on his legs, unable to move and with no access to food or drink.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inform families of discharge home when care is required
Wider context from the report “(2) The next of kin was incorrectly recorded on Mr Smith’s medical records and the family were not informed of his discharge home as part of the discharge planning that he required care.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Incomplete and inaccurate discharge nursing documentation
Wider context from the report “(4) Nursing notes in respect of Mr Smith’s discharge were incomplete, incorrect , and led to assumptions being made that Mr Smith
a. had capacity to make decisions about his care and treatment
b. was being cared for in the community.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of a bed in the home
Wider context from the report “(6) Transport staff returning Mr Smith home found he had no key. One was located and on entering the property found conditions that caused them serious concern about the hygiene and health and safety within the property with a leak, uncleanliness and exposed electrical wiring and that there was no bed .
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Incorrect recording of next-of-kin information in medical records
Wider context from the report “(2) The next of kin was incorrectly recorded on Mr Smith’s medical records and the family were not informed of his discharge home as part of the discharge planning that he required care.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to respond appropriately to deterioration while patients remain on discharge wards
Wider context from the report “(3) Mr Smith remained on a discharge ward from 2nd February until his discharge on 10th February even though he suffered a deterioration in his medical condition . Mr Smith’s capacity fluctuated during his admission, he was noted by nurses to be confused and his capacity was not reassessed.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to establish capacity before decisions about care and treatment
Wider context from the report “(4) Nursing notes in respect of Mr Smith’s discharge were incomplete, incorrect, and led to assumptions being made that Mr Smith
a. had capacity to make decisions about his care and treatment
b. was being cared for in the community.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide dietary requirements adequate for patients’ needs
Wider context from the report “(8) On readmission to hospital his dietary requirements were not adequate for his needs .
” Open source report
16 Nov 2020 Daniel Waite · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 2 Lack of coning or signage requirements for stopped works vehicles on the A20 Ashford Road View source Lack of parking restrictions for stopped works vehicles on the A20 Ashford Road View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Daniel Waite · 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
Daniel Waite was riding a pedal cycle on the A20 Ashford Road when he collided with the rear of a stationary convoy of eight tipper trucks, sustaining fatal injuries and dying at the scene on 3 July 2019. The substantive concern was that the trucks had been directed to stop on the road without parking restrictions, coning, or signage to alert other road users, and that no clearway or similar restriction was in place.
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of coning or signage requirements for stopped works vehicles on the A20 Ashford Road
Wider context from the report “(1) The A20 Ashford Road has no parking restrictions in force for this stretch of road. A total of 8 tipper lorries had been directed to stop on the A20 Ashford Road, Hollingbourne, close to the Mercure Hotel to await the deployment of motorway works on the M20 Motorway. The evidence at the inquest revealed that there was no requirement for coning or signage that may have alerted other road users to their presence .
(2) There is not at present any restriction to parking or a requirement for signage on this section of the road such as a clearway and this is of particular concern.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of parking restrictions for stopped works vehicles on the A20 Ashford Road
Wider context from the report “(1) The A20 Ashford Road has no parking restrictions in force for this stretch of road . A total of 8 tipper lorries had been directed to stop on the A20 Ashford Road, Hollingbourne, close to the Mercure Hotel to await the deployment of motorway works on the M20 Motorway. The evidence at the inquest revealed that there was no requirement for coning or signage that may have alerted other road users to their presence.
(2) There is not at present any restriction to parking or a requirement for signage on this section of the road such as a clearway and this is of particular concern.
” Open source report
Concerns raised 2 Hazardous gap and sloped surface where the path meets the river View source Lack of clarity about authority responsibility for the area View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
YUGAL LIMBU · 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
Yugal Limbu became separated from his family after drinking with friends and family, was last seen walking towards home while intoxicated, and was later found deceased in the River Stour. The inquest concluded that he accidentally fell into the river and suffered submersion. Concerns were raised about a hazardous gap and sloped surface near the footbridge at Victoria Way, including uncertainty over which local authority was responsible for the area.
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Hazardous gap and sloped surface where the path meets the river
Wider context from the report “(1) Victoria Park is well used by the public including at night and Kent Police raised a concern at the inquest hearing that there is an area by the footbridge where the path meets the river at Victoria Way, Ashford that is a hazard to the public . There is a clear gap and a sloped surface , and evidence from Kent Police is that this is dangerous for those using the path in diminished daylight or at night .
(2) This matter has been drawn to the attention of Ashford Borough Council and Kent County Council following the inquest hearing and it is unclear which authority has responsibility for the area.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about authority responsibility for the area
Wider context from the report “(1) Victoria Park is well used by the public including at night and Kent Police raised a concern at the inquest hearing that there is an area by the footbridge where the path meets the river at Victoria Way, Ashford that is a hazard to the public. There is a clear gap and a sloped surface, and evidence from Kent Police is that this is dangerous for those using the path in diminished daylight or at night.
(2) This matter has been drawn to the attention of Ashford Borough Council and Kent County Council following the inquest hearing and it is unclear which authority has responsibility for the area .
” Open source report
Concerns raised 4 Vegetation restricting pedestrians’ safe standing area beside the bus stop View source Lack of a safe pedestrian route and crossing facility near the bus stop View source Lack of signage or warning identifying the designated bus stop to approaching vehicles View source Unclear responsibility for vegetation management and adjoining land ownership at the bus stop View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christopher Thomas INNES · 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
Christopher Innes died on 25 May 2018 after being struck by a van while crossing the A28 Ashford Road in Chartham, having alighted from a bus. The concerns included the unmarked bus stop, the lack of a footway or nearby pedestrian crossing on a 50 mph road, and vegetation restricting the space available for pedestrians. There was also no clear responsibility for managing the vegetation or land adjoining the bus stop.
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Vegetation restricting pedestrians’ safe standing area beside the bus stop
Wider context from the report “(1) The presence and position of the unmarked bus stop on the carriageway, where Mr Innes alighted from the bus may be considered a hazard. The bus stop is known locally but is absent any signage or warning to approaching vehicles. The evidence revealed at the Inquest was that this may have led to him being in a position of vulnerability at the side of the carriageway, where there is no footway available for use but only a small grass verge. In order to reach a footway to progress in either direction of the A28 at this point, Mr Innes was required to cross the carriageway to which a 50mph speed limit applies and which has no pedestrian crossing facility in the vicinity.
(2) Although it is lawful for buses to stop at this location and the stop is recognised as a “hail and ride stop”, there is not at present signage indicating that this is a designated bus stop, and this is of concern given that the carriageway has a 50mph speed limit.
(3) The vegetation close to the area where buses stop includes substantial trees and hedgerows alongside the carriageway and the close proximity of this to the carriageway causes restriction for any pedestrian alighting from the bus to negotiate an appropriate place to stand on a busy rural road prior to attempting to cross a 50mph road. Although the Highways Department at Kent County Council have completed work in respect of cutting back vegetation as part of a site review on the 31st October 2018, there is no clear responsibility for the management of the cutting away of the vegetation and no clear indication of ownership of the land close to the bus stop as the Highway Authority did not concede any responsibility for the land adjoining the hard carriageway.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a safe pedestrian route and crossing facility near the bus stop
Wider context from the report “(1) The presence and position of the unmarked bus stop on the carriageway, where Mr Innes alighted from the bus may be considered a hazard. The bus stop is known locally but is absent any signage or warning to approaching vehicles. The evidence revealed at the Inquest was that this may have led to him being in a position of vulnerability at the side of the carriageway, where there is no footway available for use but only a small grass verge . In order to reach a footway to progress in either direction of the A28 at this point, Mr Innes was required to cross the carriageway to which a 50mph speed limit applies and which has no pedestrian crossing facility in the vicinity .
(2) Although it is lawful for buses to stop at this location and the stop is recognised as a “hail and ride stop”, there is not at present signage indicating that this is a designated bus stop, and this is of concern given that the carriageway has a 50mph speed limit.
(3) The vegetation close to the area where buses stop includes substantial trees and hedgerows alongside the carriageway and the close proximity of this to the carriageway causes restriction for any pedestrian alighting from the bus to negotiate an appropriate place to stand on a busy rural road prior to attempting to cross a 50mph road. Although the Highways Department at Kent County Council have completed work in respect of cutting back vegetation as part of a site review on the 31st October 2018, there is no clear responsibility for the management of the cutting away of the vegetation and no clear indication of ownership of the land close to the bus stop as the Highway Authority did not concede any responsibility for the land adjoining the hard carriageway.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of signage or warning identifying the designated bus stop to approaching vehicles
Wider context from the report “(1) The presence and position of the unmarked bus stop on the carriageway, where Mr Innes alighted from the bus may be considered a hazard. The bus stop is known locally but is absent any signage or warning to approaching vehicles . The evidence revealed at the Inquest was that this may have led to him being in a position of vulnerability at the side of the carriageway, where there is no footway available for use but only a small grass verge. In order to reach a footway to progress in either direction of the A28 at this point, Mr Innes was required to cross the carriageway to which a 50mph speed limit applies and which has no pedestrian crossing facility in the vicinity.
(2) Although it is lawful for buses to stop at this location and the stop is recognised as a “hail and ride stop”, there is not at present signage indicating that this is a designated bus stop , and this is of concern given that the carriageway has a 50mph speed limit.
(3) The vegetation close to the area where buses stop includes substantial trees and hedgerows alongside the carriageway and the close proximity of this to the carriageway causes restriction for any pedestrian alighting from the bus to negotiate an appropriate place to stand on a busy rural road prior to attempting to cross a 50mph road. Although the Highways Department at Kent County Council have completed work in respect of cutting back vegetation as part of a site review on the 31st October 2018, there is no clear responsibility for the management of the cutting away of the vegetation and no clear indication of ownership of the land close to the bus stop as the Highway Authority did not concede any responsibility for the land adjoining the hard carriageway.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for vegetation management and adjoining land ownership at the bus stop
Wider context from the report “(1) The presence and position of the unmarked bus stop on the carriageway, where Mr Innes alighted from the bus may be considered a hazard. The bus stop is known locally but is absent any signage or warning to approaching vehicles. The evidence revealed at the Inquest was that this may have led to him being in a position of vulnerability at the side of the carriageway, where there is no footway available for use but only a small grass verge. In order to reach a footway to progress in either direction of the A28 at this point, Mr Innes was required to cross the carriageway to which a 50mph speed limit applies and which has no pedestrian crossing facility in the vicinity.
(2) Although it is lawful for buses to stop at this location and the stop is recognised as a “hail and ride stop”, there is not at present signage indicating that this is a designated bus stop, and this is of concern given that the carriageway has a 50mph speed limit.
(3) The vegetation close to the area where buses stop includes substantial trees and hedgerows alongside the carriageway and the close proximity of this to the carriageway causes restriction for any pedestrian alighting from the bus to negotiate an appropriate place to stand on a busy rural road prior to attempting to cross a 50mph road. Although the Highways Department at Kent County Council have completed work in respect of cutting back vegetation as part of a site review on the 31st October 2018, there is no clear responsibility for the management of the cutting away of the vegetation and no clear indication of ownership of the land close to the bus stop as the Highway Authority did not concede any responsibility for the land adjoining the hard carriageway.
” 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 Advise bus operators not to stop near Nickle Cottages as an interim safety measure.
Verbatim wording from the response “7. KCC provided advice to bus operators using the A28 that they should consider not stopping in the vicinity of Nickle Cottages. KCC do not have to power to forbid commercial operators from stopping at that location, but are able to make such requests. That advice was accepted and at the present time no buses stop at that location as an interim measure.” Source location 2019-0124-Response-by-Kent-County-Council
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 Work with the landowner to remove low-level vegetation along the southern verge and include the cleared section in cyclic maintenance.
Verbatim wording from the response “27. Whilst the verge is not in the ownership of KCC, further investigation has indicated that a 1m may be subject to public maintenance. KCC conclude that working with the landowner that low level vegetation can be removed within the southern verge for a section from the bend west of Nickle Cottages through to a point just east of Chartham Corn Mill.” Source location 2019-0124-Response-by-Kent-County-Council
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 Install pedestrian-crossing warning signs in both directions near Nickle Cottages and additional signs for the Mansfield Farm junction.
Verbatim wording from the response “19. In order to increase the conspicuousness of pedestrians crossing the road after alighting a bus in this area on the A28, and in the absence of a formal stop or crossing point, it is proposed that a diagram 544.1 is installed in advance of the Nickel Cottage area in both directions. There are no appropriate supplementary plates which can be installed with this sign.” Source location 2019-0124-Response-by-Kent-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A hard-standing pedestrian refuge cannot be provided because the available verge is too narrow for required accessible infrastructure.
Verbatim wording from the response “25. KCC has concluded that providing a hard-standing pedestrian refuge area would involve design considerations which could not be provided at this location or within a reasonable proximity to Nickle Cottages. The main limitation to this is that permanent infrastructure must be designed for people with mobility impairments and should be to the highest standard. This can include people with physical, sensory or mental impairment but also includes people using the facility with small children, carrying heavy shopping and older people. This would place requirements to accommodate facility widths and access arrangements which cannot be constructed within the available space of the verge.” Source location 2019-0124-Response-by-Kent-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A bus-stop road marking would not address the concern because it marks only a fixed stop and does not provide advance warning.
Verbatim wording from the response “21. Bus stops can be marked using the diagram 1025.1 TSRGD 2016. This marking is used on fixed bus stops in urban areas predominantly to prevent parking within the bus stop location. This marking is not used in rural areas and would not be considered to provide an advance warning of the presence of a bus stop as it is marked at the exact location of the stop. For that reason KCC does not consider that such a marking would address the concerns outlined in the PFD report.” Source location 2019-0124-Response-by-Kent-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation KCC does not accept that absent signage contributed to the death; pedestrian warning signs may nevertheless provide some betterment.
Verbatim wording from the response “20. KCC does not concede that the absence of signage was in any way a contributing factor in the death of Mr Innes, however it does consider that the installation of warning signs to warn of pedestrians in road ahead may provide some betterment for users of the bus service at this location.” Source location 2019-0124-Response-by-Kent-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation KCC does not accept that vegetation or verge condition contributed to the death, although vegetation clearance may improve visibility and access.
Verbatim wording from the response “28. KCC have also decided that this can be included in future cyclic maintenance in order to keep sections of low level vegetation between the established trees. KCC does not concede that the vegetation and the condition of the verge was in any way contributory to the death of Mr Innes, but does consider that this action will provide a betterment to the service in terms of increasing the opportunities to access the bus service and also increase the visibility of any pedestrians standing on the verge to approaching drivers.” Source location 2019-0124-Response-by-Kent-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No specific traffic sign is available under the regulations to warn drivers specifically about a bus stop ahead.
Verbatim wording from the response “16. The Traffic Signs Regulations and General Directions 2016 (TSRGD 2016) does not prescribe any highway sign which warns of the presence of a bus stop. The only signs which can warn of other hazards is diagram 562 below. There are 15 supplementary plates which can accompany this sign to advise drivers of the specific hazard. None of these supplementary plates relate to the presence of a bus stop. Without the provision of a supplementary plate, drivers will not be able to understand what they need to prepare for ahead and this warning will be less effective.” Source location 2019-0124-Response-by-Kent-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A controlled pedestrian crossing is not considered appropriate because pedestrian crossing numbers and general footway use are minimal.
Verbatim wording from the response “33. Controlled pedestrians’ crossings in the form of a zebra, pelican or puffin crossing are only considered where there are high numbers of pedestrians crossing within a small area and where the volume of traffic provides very little opportunity for pedestrians to cross a road. In this instance the level of pedestrians crossing the road is very minimal and level of pedestrian traffic generally on the provided footways is very low. A controlled crossing at this location is therefore not considered appropriate.” Source location 2019-0124-Response-by-Kent-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation An uncontrolled crossing cannot be provided because there is no southern footway and insufficient verge width for an accessible facility.
Verbatim wording from the response “34. An uncontrolled crossing in the form of dropped kerbs on either side of the road, can only be provided where there is a continuous route of footways. In this instance there is no southern footway and the available verge width is insufficient to provide a facility suitable for all users.” Source location 2019-0124-Response-by-Kent-County-Council
Open published response
23 Feb 2017 Luke Mumford · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 3 Narrow carriageway View source Lack of road lighting at night View source Lack of kerb or pavement bordering the road View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Luke Mumford · 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
Luke Mumford died at the scene after his car left Pilgrim's Way, struck a tree and came to rest in a field on 23 November 2016. The report raised concern that the road was unsafe to drive on at the 70 mph speed limit because it was narrow, unlit and bordered by hedgerows and trees.
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Narrow carriageway
Wider context from the report “(1) The nature of the road is such that it is unsafe to drive at 70 mph in that
i) The carriageway is very narrow
ii) The road is unlit at night
iii) The road is not bordered by any kerb or pavement but rather hedgerows and trees
iv) At Inquest the evidence of a Police Pursuit Driver and Accident Collision Investigator was that they had felt unsafe traversing the road above 50 mph.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of road lighting at night
Wider context from the report “(1) The nature of the road is such that it is unsafe to drive at 70 mph in that
i) The carriageway is very narrow
ii) The road is unlit at night
iii) The road is not bordered by any kerb or pavement but rather hedgerows and trees
iv) At Inquest the evidence of a Police Pursuit Driver and Accident Collision Investigator was that they had felt unsafe traversing the road above 50 mph.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of kerb or pavement bordering the road
Wider context from the report “(1) The nature of the road is such that it is unsafe to drive at 70 mph in that
i) The carriageway is very narrow
ii) The road is unlit at night
iii) The road is not bordered by any kerb or pavement but rather hedgerows and trees
iv) At Inquest the evidence of a Police Pursuit Driver and Accident Collision Investigator was that they had felt unsafe traversing the road above 50 mph.
” 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 Programme a scheme to reduce the road’s speed limit to 50 mph.
Verbatim wording from the response “The road is narrow and unlit and is bordered by hedgerows and trees. In its context as a ‘de-restricted’ dual carriageway the speed limit is 70mph, however it should be noted that the speed limit is the absolute maximum speed – it doesn’t mean it is safe to drive at this speed in all conditions. Notwithstanding this, in response to the incident and the very clear coroner recommendation, Kent County Council will be programming a scheme to reduce the speed limit of the road to 50mph.” Source location 2017-0047-Response-by-Kent-County-Council
Open published response
23 Nov 2015 Alan Ludlow · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 3 Failure to keep residential placement suitability under review View source Failure to provide receiving care homes with relevant incident information View source Lack of relevant information for residential and nursing placement assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alan Ludlow · 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
Alan Ludlow died in hospital after suffering a subdural haematoma following a blow to his face from another resident at his care home, and subsequently developing pneumonia. The principal concern was that relevant information about the incident was not passed to the care home where the other resident was later placed, and that residential placements and changing needs must be appropriately assessed and reviewed.
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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to keep residential placement suitability under review
Wider context from the report “Once a person is placed in a home the suitability of that placement must be kept under review to ensure that any changing needs continued to be met . It stands to reason if people are not appropriately placed there will be risks of harm to both themselves and to others.
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide receiving care homes with relevant incident information
Wider context from the report “The specific issue which came to my attention in this case was this:
After the incident between Mr Ludlow and RT, RT was moved from the home to other accommodation. However, more recently, following deterioration in his mental state, he was admitted to another care home. This care home was not provided with any information about the incident which led to Mr Ludlow’s death by RT’s social worker or those who would be expected to know about the incident .
The only reason the care home in fact became aware of the background was because it was part of the same group of care homes to which the original care home belonged and it was only by chance that someone recognised the name and made the connection .
” 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 Kent County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of relevant information for residential and nursing placement assessments
Wider context from the report “One of the matters which became apparent during the course of the evidence related to the issue of ensuring that when someone is assessed for a particular placement within residential and nursing environments that those undertaking the assessments and the home in which a person is placed, have all relevant information to ensure that the placement is the most appropriate for that person .
” 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