Recipient

Maidstone and Tunbridge Wells NHS Trust

Pin Request correction

First report 19 May 2014•Latest report 3 Dec 2021

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
9

Naming this recipient

Published responses
78%

Found for named reports

Concerns addressed
22

Across all linked responses

Stated actions
63

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.

78%published responses found
63stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Mid Kent and Medway

    AI-generated summary

    TERENCE TALBOT · 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

    Terence Talbot died at Maidstone & Tunbridge Wells NHS Trust on 9 April 2020 from multiorgan failure due to empyema and pneumonia associated with DRESS Syndrome, following a severe reaction to prescribed medication for bipolar affective disorder. The concerns included repeated discharge and readmission, lack of formal mental-capacity assessments, insufficient dermatology review and emollient application, inadequate food and fluid leading to malnutrition, and issues concerning a requirement to attend in person to claim benefits while severely ill.

    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of formal mental capacity assessments for treatment decisions

    Wider context from the report

    “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February. (1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression. (2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments. (3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of regular dietitian input for malnutrition

    Wider context from the report

    “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February. (1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression. (2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments. (3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of application of emollients for severe exfoliative dermatitis

    Wider context from the report

    “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February. (1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression. (2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments. (3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Requirement for severely ill inpatients to attend benefit offices in person

    Wider context from the report

    “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February. (1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression. (2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments. (3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate provision of food and fluid to meet patient needs

    Wider context from the report

    “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February. (1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression. (2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments. (3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of multidisciplinary meetings to focus on treatment needs

    Wider context from the report

    “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February. (1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression. (2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments. (3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of specialist dermatology review for severe exfoliative dermatitis

    Wider context from the report

    “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February. (1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression. (2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments. (3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection. ”
    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

    Nominate a lead clinician to review and clarify urgent and non-urgent dermatology referral pathways.

    Verbatim wording from the response

    “With regards to referral pathways and specialty dermatology referrals, the Trust’s Clinical Director for specialist medical services has been asked to nominate a lead clinician to review the pathway into”

    Source location

    2021-0419-Response-from-Maidstone-Hospital_Published
    Page 1 · response
    Published 16 December 2021

    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

    Provide mandatory tailored capacity-assessment training and conduct Trust-wide audit and monitoring.

    Verbatim wording from the response

    “Along with the above training, the Trust continues to provide tailored, bespoke training sessions to all staff regarding the vital importance of capacity assessments. Again, regular audit and monitoring is being applied Trust wide. Such training is mandatory for each clinical member of staff.”

    Source location

    2021-0419-Response-from-Maidstone-Hospital_Published
    Page 3 · response
    Published 16 December 2021

    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

    Complete and weekly repeat MUST nutrition screening for all patients to identify deterioration and dietetic intervention needs.

    Verbatim wording from the response

    “▪ All patients continue to have a Malnutrition Universal Screening Tool (MUST) score completed on admission and weekly thereafter to detect any deterioration and ensure dietetic intervention;”

    Source location

    2021-0419-Response-from-Maidstone-Hospital_Published
    Page 2 · response
    Published 16 December 2021

    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

    Scope whether to include or contract external dermatology services within the current pathway.

    Verbatim wording from the response

    “dermatology services for critical diseases, to ensure there is clarity regarding urgent and non-urgent cases. It is expected that the identified clinician will take up this role in by the end of this month. Scoping the option of including/contracting East Kent Hospitals University Foundation Trusts Dermatology Services into our current pathway will form part of this clinicians’ commission. Once this has been completed additional training will be commissioned by the Trust to increase the awareness to our staff regarding the services & pathways which are available. The objective of this training will be to ensure that there is Trust wide awareness of available support systems in relation to dermatology.”

    Source location

    2021-0419-Response-from-Maidstone-Hospital_Published
    Page 2 · response
    Published 16 December 2021

    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

    Recruit ward-based therapy assistants to support eating, drinking and speech and language therapy.

    Verbatim wording from the response

    “▪ Ward-based therapy assistants are being recruited. Their focus will also include assisting patients with eating and drinking and speech and language therapy.”

    Source location

    2021-0419-Response-from-Maidstone-Hospital_Published
    Page 2 · response
    Published 16 December 2021

    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

    Strengthen monitoring of inpatient food charts through multidisciplinary discussions with the neighbouring mental health Trust.

    Verbatim wording from the response

    “In order to ensure comprehensive learning from this matter, and as part of the MDT discussions with our neighbouring mental health Trust, the Trust is committed to ensuring further vigilance with regards to the monitoring of food charts for inpatients with physical and mental health needs.”

    Source location

    2021-0419-Response-from-Maidstone-Hospital_Published
    Page 2 · response
    Published 16 December 2021

    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

    Introduce a clinical advisor role and appoint a Mental Capacity Act clinical practitioner to support complex capacity cases.

    Verbatim wording from the response

    “Further, the Trust has introduced a new clinical advisor role as the lead clinician on capacity. The Trust has also appointed a new Mental Capacity Act clinical practitioner who will be available to assist the wards in dealing with complex cases. These leads will strengthen our oversight in ensuring the appropriate considerations around capacity are comprehensively covered.”

    Source location

    2021-0419-Response-from-Maidstone-Hospital_Published
    Page 3 · response
    Published 16 December 2021

    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

    Commission and complete an audit of consent and mental capacity practices.

    Verbatim wording from the response

    “Response The Court is respectfully advised that the Trust has commissioned an audit into its consent and capacity practices. The external Trust Auditor has found that the Trust is broadly performing well. The recommendations from this review have been discussed by the Directorate leads and taken forward as part of the DATIX action plan noted above.”

    Source location

    2021-0419-Response-from-Maidstone-Hospital_Published
    Page 3 · response
    Published 16 December 2021

    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

    Commission additional staff training on available dermatology services, referral pathways and support systems.

    Verbatim wording from the response

    “dermatology services for critical diseases, to ensure there is clarity regarding urgent and non-urgent cases. It is expected that the identified clinician will take up this role in by the end of this month. Scoping the option of including/contracting East Kent Hospitals University Foundation Trusts Dermatology Services into our current pathway will form part of this clinicians’ commission. Once this has been completed additional training will be commissioned by the Trust to increase the awareness to our staff regarding the services & pathways which are available. The objective of this training will be to ensure that there is Trust wide awareness of available support systems in relation to dermatology.”

    Source location

    2021-0419-Response-from-Maidstone-Hospital_Published
    Page 2 · response
    Published 16 December 2021

    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

    The Trust does not itself provide dermatology services, limiting its direct responsibility for specialist dermatology referral.

    Verbatim wording from the response

    “Response Awareness and escalation techniques form part of training that is delivered to nursing colleagues. As identified within the hearing, the Trust, (albeit not in a timely manner), did obtain community dermatology opinion and support (the Court will recall that the Trust does not provide dermatology services itself).”

    Source location

    2021-0419-Response-from-Maidstone-Hospital_Published
    Page 1 · response
    Published 16 December 2021

    Open published response

  2. Mid Kent and Medway

    AI-generated summary

    KATHERINE MABEL HOGAN · 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

    Katherine Hogan died at Maidstone Hospital on 31 August 2019 after sustaining a severe head injury and major haemorrhage from a high-impact fall from a trolley in the clinical decision unit. The concerns included staff shortages, the use of an unsuitable area for keeping a patient overnight, and an outstanding request for increased staffing that had not been addressed by the Trust.

    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to keep patients in a suitable area overnight

    Wider context from the report

    “(1) Staff shortages contributed to the patient being left the clinical decisions area of the unit on a trolley. This was not an area that was suitable to keep a patient overnight. Staff shortages were reported to those responsible for the hospital. (2) Evidence is that the unit has moved and has been reconfigured, however there remains an outstanding request for increased staffing that has not been addressed by the Trust. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of adequate staffing in the unit

    Wider context from the report

    “(1) Staff shortages contributed to the patient being left the clinical decisions area of the unit on a trolley. This was not an area that was suitable to keep a patient overnight. Staff shortages were reported to those responsible for the hospital. (2) Evidence is that the unit has moved and has been reconfigured, however there remains an outstanding request for increased staffing that has not been addressed by the Trust. ”
    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

    Escalate staffing concerns through senior nursing and site-practitioner channels, record them on DATIX, and monitor them through staffing reviews.

    Verbatim wording from the response

    “In light of these facts, and the concern noted within your Report, the Trust has comprehensively considered this matter further. Going forward staff have been reminded that if staffing levels are identified as a concern this should be escalated by the senior nursing team and site practitioner to arrange cover. Staffing concerns must also be reported on the Trust’s incident reporting system (DATIX) – so that these levels may be monitored and kept under review.”

    Source location

    2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
    Page 2 · response
    Published 24 December 2020

    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

    Continue recruiting Emergency Department nurses and substantially recruit newly created additional department posts.

    Verbatim wording from the response

    “Safe staffing levels have been reassessed since the reconfiguration of the department and incorporated into the rotas. These levels also form part of the basis of safe staffing reporting to the Chief Nurse. Senior nursing support has been increased with the successful recruitment of 3 additional Emergency Medicine Matrons. The senior support Matron cover has meant that there is cover 7 days a week on site to support the staff within the department. There is an active ongoing recruitment campaign for Emergency Department nurses with regular recruitment days taking place.”

    Source location

    2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
    Page 3 · response
    Published 24 December 2020

    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

    Update the CDU standard operating process to define its short-stay purpose, admission and exclusion criteria, discharge planning, and prohibition on placing patients requiring admission there.

    Verbatim wording from the response

    “As the Court have noted, the Clinical Decision Unit (CDU) has been reconfigured. In line with this, the Trust now confirms that a Standard Operating Process (SOP) as regards the CDU has been updated and amended. This SOP sets out the intended use of the CDU. The provisions of this SOP include:”

    Source location

    2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
    Page 2 · response
    Published 24 December 2020

    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

    Provide increased senior nursing support by recruiting three Emergency Medicine Matrons and establishing seven-day on-site cover.

    Verbatim wording from the response

    “Safe staffing levels have been reassessed since the reconfiguration of the department and incorporated into the rotas. These levels also form part of the basis of safe staffing reporting to the Chief Nurse. Senior nursing support has been increased with the successful recruitment of 3 additional Emergency Medicine Matrons. The senior support Matron cover has meant that there is cover 7 days a week on site to support the staff within the department. There is an active ongoing recruitment campaign for Emergency Department nurses with regular recruitment days taking place.”

    Source location

    2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
    Page 3 · response
    Published 24 December 2020

    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

    Introduce twice-daily Trust-wide safe-staffing meetings to identify staffing risks and required mitigating actions.

    Verbatim wording from the response

    “As standard practice, staffing concerns are escalated at each daily site meeting. The Nurse in charge has the responsibility to discuss / escalate staffing deficits and plans to a Matron. This ‘horizon planning’ aids early identification of staffing shortages so that temporary / agency staff may be sourced as required. Nursing staff have also been reminded that their twice daily safety huddles in each ward/department should be used to consider all concerns, including any staffing issues. We have also introduced twice daily trust-wide safe staffing meetings, chaired by the Chief Nurse and attended by the Divisional Directors of Nursing and Quality. These meetings are used to understand risks anywhere in the Trust in relation to staffing and identify actions required to mitigate these risks.”

    Source location

    2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
    Page 2 · response
    Published 24 December 2020

    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

    Update and disseminate the department protocol and admission criteria, including closure of the unit when suitable staffing is unavailable.

    Verbatim wording from the response

    “The patient was left in the CDU on a trolley due to the historical department protocol not being followed. The patient did not meet the admission criteria for the CDU however was still admitted to this area. As a result of this incident, action has been taken to update the department protocol and admission criteria. The updated department protocol and admission criteria has been disseminated to all staff within the department. The updated department protocol now states that the unit must be closed if there is no suitable staff allocated to the unit.”

    Source location

    2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
    Page 2 · response
    Published 24 December 2020

    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

    Reassess safe staffing levels, incorporate them into rotas, and use national recommendations to benchmark staffing and inform safe-staffing reporting.

    Verbatim wording from the response

    “Safe staffing levels have been reassessed since the reconfiguration of the department and incorporated into the rotas. These levels also form part of the basis of safe staffing reporting to the Chief Nurse. Senior nursing support has been increased with the successful recruitment of 3 additional Emergency Medicine Matrons. The senior support Matron cover has meant that there is cover 7 days a week on site to support the staff within the department. There is an active ongoing recruitment campaign for Emergency Department nurses with regular recruitment days taking place.”

    Source location

    2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
    Page 3 · response
    Published 24 December 2020

    Open published response

  3. North West Kent

    AI-generated summary

    Jonathan Richard McCARTHY · 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

    Jonathan Richard McCarthy was admitted to hospital with confusion, aspiration pneumonia, sepsis, acute kidney injury and swallowing difficulties, and later deteriorated with another aspiration pneumonia and hyperglycaemia. The stated concerns were failures to correctly monitor blood sugar and ketones, administer the correct insulin dose, and provide adequate nursing care and escalation to the medical team.

    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to administer the correct dose of insulin

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The Trust failed to correctly monitor the blood sugar and ketone testing of Jonathan Richard McCarthy (2) The Trust failed to administer the correct does of insulin (3) There was inadequate nursing care and a failure to escalate to the medical team when it was clear this should be carried out. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to correctly monitor blood sugar and ketone testing

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The Trust failed to correctly monitor the blood sugar and ketone testing of Jonathan Richard McCarthy (2) The Trust failed to administer the correct does of insulin (3) There was inadequate nursing care and a failure to escalate to the medical team when it was clear this should be carried out. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to escalate to the medical team

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The Trust failed to correctly monitor the blood sugar and ketone testing of Jonathan Richard McCarthy (2) The Trust failed to administer the correct does of insulin (3) There was inadequate nursing care and a failure to escalate to the medical team when it was clear this should be carried out. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate nursing care

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The Trust failed to correctly monitor the blood sugar and ketone testing of Jonathan Richard McCarthy (2) The Trust failed to administer the correct does of insulin (3) There was inadequate nursing care and a failure to escalate to the medical team when it was clear this should be carried out. ”
    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

    Develop and introduce connected blood-glucose and ketone meters with real-time dashboard escalation, replacing existing meters and training staff.

    Verbatim wording from the response

    “The Trust has also been out to tender for a blood glucose and ketone testing meter that has the capability of linking into the existing clinical observation monitoring tool (Nervecentre) which would record and escalate results accordingly. In addition blood ketone testing machines have been purchased and assigned to key locations in the trust with the aim to ultimately have them on each ward. The Emergency Departments on both sites have these in place and appropriate training has been rolled out to the nursing staff. In addition the Diabetic Nurse Specialists also carry ketone testing machines to support access and training to the ward staff as and when required.”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 2 · response
    Published 14 August 2019

    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

    Disseminate the blood-monitoring guidance through presentations at remaining Trust Clinical Governance days.

    Verbatim wording from the response

    “The new guidance will continue to be disseminated throughout the Trust by way of short presentations at the remaining Trust Clinical Governance days over the coming months delivered by either the Diabetes Specialist Nurses or the lead Diabetic Consultants.”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 3 · response
    Published 14 August 2019

    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

    Deliver ward-based diabetes-monitoring training through specialist nurses and link nurses.

    Verbatim wording from the response

    “Ongoing adhoc ward training is to be delivered by the Diabetes Specialist Nurses to raise awareness of the new Blood Monitoring guidance on the wards with support from identified link nurses. In addition we have worked with the Directorate and Communications team to develop a strategy to raise awareness throughout the organisation in regard to the process of close diabetic monitoring. Some of this work included the use of the Patient Safety Calendar to focus on the key elements of diabetic management, a launch of the Blood Monitoring Guideline and bespoke Training days for Nurses and Clinical Support Workers.”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 3 · response
    Published 14 August 2019

    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

    Purchase and deploy blood-ketone testing machines to key locations, with emergency-department nursing training and specialist-nurse support.

    Verbatim wording from the response

    “The Trust has also been out to tender for a blood glucose and ketone testing meter that has the capability of linking into the existing clinical observation monitoring tool (Nervecentre) which would record and escalate results accordingly. In addition blood ketone testing machines have been purchased and assigned to key locations in the trust with the aim to ultimately have them on each ward. The Emergency Departments on both sites have these in place and appropriate training has been rolled out to the nursing staff. In addition the Diabetic Nurse Specialists also carry ketone testing machines to support access and training to the ward staff as and when required.”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 2 · response
    Published 14 August 2019

    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 an organisation-wide diabetes-monitoring awareness strategy using the Patient Safety Calendar, guideline launch and bespoke training days.

    Verbatim wording from the response

    “Ongoing adhoc ward training is to be delivered by the Diabetes Specialist Nurses to raise awareness of the new Blood Monitoring guidance on the wards with support from identified link nurses. In addition we have worked with the Directorate and Communications team to develop a strategy to raise awareness throughout the organisation in regard to the process of close diabetic monitoring. Some of this work included the use of the Patient Safety Calendar to focus on the key elements of diabetic management, a launch of the Blood Monitoring Guideline and bespoke Training days for Nurses and Clinical Support Workers.”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 3 · response
    Published 14 August 2019

    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

    Provide monthly induction training for clinical support workers, registered nurses and junior doctors on diabetic monitoring, equipment, escalation and referrals.

    Verbatim wording from the response

    “Ongoing monthly training has been in place for new Clinical Support Workers and Registered Nurses and this is undertaken during their first weeks on induction to the trust where diabetic management is highlighted in bite-sized sessions. This is delivered by the Diabetes Specialist Nurses on both sites. This demonstrates the use of equipment (by the Point of Care Team), the new algorithm for the recognition and management of hyper- and hypo-glycaemia and how to request in-patient referrals to the Diabetes Team and escalate for medical attention. The Blood Glucose Guideline also forms part of the Junior doctors induction programme which is also undertaken by the Diabetes Team.”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 1 · response
    Published 14 August 2019

    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 pharmacy drug-chart auditing process and disseminate serious-incident learning through the monthly Medicines Safety News editorial.

    Verbatim wording from the response

    “The Pharmacy Department are undertaking a review of the auditing process in regard to Drug charts as this was not identified in the case of Mr McCarthy and is being discussed and addressed at their team meetings. The Serious Incident findings are being highlighted in their monthly learning editorial (Medicines Safety News).”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 2 · response
    Published 14 August 2019

    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

    Deliver targeted staff training and share case learning on testing, abnormal-result response and escalation to medical or diabetes teams.

    Verbatim wording from the response

    “As outlined in response to question (1), this aspect of Mr McCarthy’s care has been addressed directly with the staff concerned on those on the ward with specific training and the learning from Mr McCarthy’s case has been shared. The introduction of the algorithm, the raised awareness of the importance of testing and acting/escalating abnormal results have been outlined and incorporated into the new guidance. This includes the element of how and when to escalate to medical teams or diabetic nurse specialists for assistance and review.”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 2 · response
    Published 14 August 2019

    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 the approved blood-glucose monitoring guideline, including traffic-light interpretation, hypoglycaemia management and escalation procedures.

    Verbatim wording from the response

    “It was identified during the Serious Incident investigation that the staff concerned were unsure of the appropriate procedures relating to the monitoring of blood sugar and ketone testing therefore a Trust Guideline for capillary blood glucose monitoring for inpatients and day cases with Diabetes Mellitus over the age of 16 years has been written and approved by the Medical Specialities Directorate. This guideline is in keeping with the standard set by the National Inpatient Diabetes Audit. The guideline has been out for wide consultation with comments from clinicians across the trust being received. Contained within the Guideline is a coloured “traffic light” risk tool to assist staff on the wards to interpret the results of blood sugar and ketone testing, with recommended actions to undertake and escalation as appropriate.”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 1 · response
    Published 14 August 2019

    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

    Include dedicated blood-glucose-guideline training and case learning in junior-doctor induction programmes.

    Verbatim wording from the response

    “Junior doctor induction programmes will now include dedicated training in the Blood Glucose monitoring guideline and the key learning points from Mr McCarthy’s case.”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 2 · response
    Published 14 August 2019

    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

    Deliver additional registered-nurse and clinical-support-worker study days using the case and related serious incidents as teaching scenarios.

    Verbatim wording from the response

    “In addition two further specific study days have been booked for Registered Nurses and a half day for Clinical Support Workers where the above will be discussed in more depth and the use of Mr McCarthy’s case and any other related Serious Incidents used as teaching scenarios.”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 2 · response
    Published 14 August 2019

    Open published response

  4. Kent (North-West)

    AI-generated summary

    Timothy Alastair Mason · 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

    Timothy Alastair Mason became unwell over several days, attended Tunbridge Wells Hospital twice on 16 March 2018, and died later that day after treatment. The inquest recorded the medical cause of death as meningococcal septicaemia and identified concerns about failure to diagnose and treat him, his discharge while seriously unwell, and his not receiving the Men ACWY vaccination. Further concerns related to staff instructions and training and the systems for offering, recording and monitoring vaccination.

    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear staff instructions for Emergency Department management of patients with symptoms suggestive of sepsis

    Wider context from the report

    “(1) The reasons for the failure to correctly diagnose and treat Timothy on the 16th March 2018 at 03.30. What staff instructions were given to the doctors and nurses in the Emergency Department at the hospital for dealing with patients with symptoms suggestive of sepsis and what tests should have been carried out and why they were not done. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide Men ACWY vaccination to eligible patients

    Wider context from the report

    “(5) How it happened that Timothy did not receive the Men ACWY vaccination and what systems are in place to ensure patients do receive the vaccination, how this is provided and monitored by NHS England and whether this is adequate or should be improved to avoid patients failing to receive the vaccine. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate systems for providing and monitoring Men ACWY vaccination

    Wider context from the report

    “(5) How it happened that Timothy did not receive the Men ACWY vaccination and what systems are in place to ensure patients do receive the vaccination, how this is provided and monitored by NHS England and whether this is adequate or should be improved to avoid patients failing to receive the vaccine. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to correctly diagnose and treat patients with suspected sepsis

    Wider context from the report

    “(1) The reasons for the failure to correctly diagnose and treat Timothy on the 16th March 2018 at 03.30. What staff instructions were given to the doctors and nurses in the Emergency Department at the hospital for dealing with patients with symptoms suggestive of sepsis and what tests should have been carried out and why they were not done. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to carry out required tests for patients with symptoms suggestive of sepsis

    Wider context from the report

    “(1) The reasons for the failure to correctly diagnose and treat Timothy on the 16th March 2018 at 03.30. What staff instructions were given to the doctors and nurses in the Emergency Department at the hospital for dealing with patients with symptoms suggestive of sepsis and what tests should have been carried out and why they were not done. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Discharge of very unwell patients before required tests are carried out

    Wider context from the report

    “(2) Why was Timothy discharged home on the morning of the 16th March 2018 when he was clearly very unwell and tests had not been carried out. ”
    Open source report

  5. Kent (North-West)

    AI-generated summary

    Frances Olwyn Coppaccini · 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

    Frances Olwyn Coppaccini died on 9 October 2012 at Tunbridge Wells Hospital following the birth of her child. The report raised concerns about retained placental tissue after caesarean section, failure to follow the post-partum haemorrhage protocol, supervision of anaesthetic staff, delays in obtaining urgent specialist help, and inadequate hospital note keeping.

    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in requesting urgent help from an intensivist or anaesthetist

    Wider context from the report

    “4. What steps have been taken to avoid there being delays in a request for urgent help for an intensivist/anaesthetist. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide staff grade anaesthetists and supervisors with the respective identities of the parties involved

    Wider context from the report

    “3. Supervision – What action has been taken to ensure that staff grade anaesthetists are supervised and that both the staff grade and supervisor are provided details of the respective identities of the parties involved. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to check that no part of the placenta remains following caesarean section delivery

    Wider context from the report

    “1. What action is taken to check and ensure no part of the placenta remains following a caesarean section delivery? ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate clinical note keeping at the hospital

    Wider context from the report

    “5. The Inquest showed a number of examples of inadequate note keeping at the hospital – what actions have been taken to ensure this is not repeated in the future. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to follow the protocol for management of postpartum haemorrhage

    Wider context from the report

    “2. The protocol for the management of post partum haemorrhage was not followed by the medical staff. What procedures have been instigated to avoid this happening again. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to supervise staff grade anaesthetists

    Wider context from the report

    “3. Supervision – What action has been taken to ensure that staff grade anaesthetists are supervised and that both the staff grade and supervisor are provided details of the respective identities of the parties involved. ”
    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

    Review documentation requirements and conduct regular local and national clinical documentation audits.

    Verbatim wording from the response

    “We continually review the documentation to be completed in addition to noting in the healthcare records, to ensure they are easy to use in the highly-pressurised situations in which our staff work.”

    Source location

    2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 5 · response
    Published 19 February 2017

    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

    Deliver mandatory annual multidisciplinary PROMPT training, including emergency drills, communication, escalation, teamwork and updated policy guidance.

    Verbatim wording from the response

    “The PROMPT method of training (Practical Obstetric Multi-Professional Training), which is a training programme run in maternity units across the country, incorporates the management of a range of Obstetric emergency situations with interactive drills and workshops to provide 'hands on' experience of practical skills and decision-making. The components of team working, including training for communication in an emergency, feature throughout the course. In the training sessions, which are attended by multidisciplinary groups of staff, each member of staff plays the role in the training scenario that they would play in a real situation.”

    Source location

    2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 2 · response
    Published 19 February 2017

    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

    Provide annual theoretical and practical training for Obstetricians and Midwives to strengthen caesarean-section and haemorrhage management.

    Verbatim wording from the response

    “We acknowledge, with regret, that this process was not successfully followed in Mrs Cappuccini’s case, however in the intervening years since this tragic incident all of our Obstetricians and Midwives have completed several rounds of annual training (theoretical and practical) to ensure that they are as qualified and experienced as possible to ensure better outcomes in the future.”

    Source location

    2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 2 · response
    Published 19 February 2017

    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

    Provide dedicated consultant anaesthetist cover for elective caesarean sections, leaving the Delivery Suite consultant available for emergencies.

    Verbatim wording from the response

    “4) What steps have been taken to avoid there being delays in a request for urgent help for an intensivist/anaesthetist.”

    Source location

    2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 4 · response
    Published 19 February 2017

    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

    Require staff caring for patients at risk of postpartum haemorrhage to read the protocol and record compliance.

    Verbatim wording from the response

    “2) The protocol for the management of post-partum haemorrhage was not followed by the medical staff. What procedures have been instigated to avoid this happening again.”

    Source location

    2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 2 · response
    Published 19 February 2017

    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

    Establish electronic rota and induction arrangements identifying anaesthetic supervision, consultants and emergency contact routes for staff-grade, trainee and locum anaesthetists.

    Verbatim wording from the response

    “All Anaesthetists have an electronic rota app on their phones and can identify who is the staff grade on for Labour Ward and who is the consultant covering.”

    Source location

    2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 4 · response
    Published 19 February 2017

    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

    Provide documentation training through annual departmental training, mandatory Information Governance training, legal updates and clinical leadership programmes.

    Verbatim wording from the response

    “Documentation training underpins core training for nurses, doctors and allied health practitioners at all levels within the organisation. All staff are aware of the importance of clear, and contemporaneous record keeping and the balance that must be struck between this obligation and the immediate care and treatment to be provided to our patients.”

    Source location

    2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 5 · response
    Published 19 February 2017

    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

    Audit postpartum-haemorrhage documentation annually and review the proforma, including its new theatre fluid-input and output section.

    Verbatim wording from the response

    “We are always seeking to improve our service and minimise patient harm, and to that end we constantly review our processes, training and documentation. In light of the potential issues regarding drug use in PPH cases, our Pharmacy team have created a new guidance document for staff (copy enclosed). The Obstetric department is also reviewing fluid replacement at PPH, and undertakes yearly audits regarding PPH documentation including the regular review of the PPH Proforma to ensure it meets the needs of staff in the time critical situations they work in. The latest version of the PPH Proforma, which includes a new section for recording fluid input and output in theatre, is enclosed for your information.”

    Source location

    2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 3 · response
    Published 19 February 2017

    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

    Maintain and distribute real-time, paper, whiteboard and weekly emailed anaesthetic rotas with direct contact details and hospital-specific terminology.

    Verbatim wording from the response

    “The Anaesthetic and Obstetric departments, as well as switchboard, have access to a real-time electronic rota for the Anaesthetic department. There is also a weekly paper rota kept on Delivery Suite, and consultants add their name and bleep number to the whiteboard in the Labour Ward handover room. Additionally, the rotas are emailed out weekly to all senior staff and Delivery Suite Band 7 Midwives.”

    Source location

    2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 4 · response
    Published 19 February 2017

    Open published response

  6. Mid Kent and Medway

    AI-generated summary

    Matthew Crowley · 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

    Matthew Crowley, aged 39, presented to Maidstone Hospital acutely unwell with sepsis and multiple organ failure, and died at Pembury Hospital at 06.47 on 10 June 2015 after transfer. The report identified concerns including delays in triage, senior medical review, treatment escalation, decision-making and transfer, as well as inadequate communication with the receiving ITU.

    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in ownership and onward management of patients

    Wider context from the report

    “(3) There was a delay in ownership and onward management of the patient which resulted in timely decisions not being made. On call consultants responsible for those decisions were not aware of the patient deteriorating because they did not personally review the patient and were not informed of, or did not secure updated information themselves of how acutely unwell the patient was. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in senior doctor review of PAR 5 patients

    Wider context from the report

    “(2) The patient was not seen by a doctor for 2 hours 20 minutes despite being PAR 5 and requiring therefore an immediate review by a senior doctor ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to inform the receiving ITU of patient transfers

    Wider context from the report

    “(5) The ITU of the hospital to which the patient was transferred were not informed of the transfer ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to operate a Rapid Access Treatment Protocol for timely triage

    Wider context from the report

    “(1) A Rapid Access Treatment Protocol (RATT) was not in operation as a result of a busy A&E department which was short staffed. This resulted in a delay in the triage ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of on-call consultants to obtain or receive updated information about patient deterioration

    Wider context from the report

    “(3) There was a delay in ownership and onward management of the patient which resulted in timely decisions not being made. On call consultants responsible for those decisions were not aware of the patient deteriorating because they did not personally review the patient and were not informed of, or did not secure updated information themselves of how acutely unwell the patient was. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in securing acceptance by an appropriate vascular site

    Wider context from the report

    “(4) Despite a vascular site declining to accept the patient until his renal function was optimised and a CT angiogram performed, a delay was caused by enquiries being made whether a second vascular site would accept the patient ”
    Open source report

  7. North West Kent

    AI-generated summary

    Sandra Rhoda Marion Wood · 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

    Sandra Rhoda Marion Wood was sent to Tunbridge Wells Hospital on 17 April 2015 with a suspected bowel obstruction and was discharged with a diagnosis of UTI and constipation. She was found collapsed at home the following day, taken to Maidstone General Hospital, and died later that day; the post-mortem recorded bowel obstruction due to adhesions. The concerns included the lack of routine weekend CT scanning facilities, the procedure required for urgent scans, and the delay to scanning until after the weekend.

    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of weekend facilities for routine CT scans

    Wider context from the report

    “(1) The NHS Trust does not have facilities for routine CT scans to be carried out during weekends (2) If an urgent CT scans are necessary a specific application procedure has to be put in place (3) In this case despite the requirements for an urgent scan to be undertaken in a potentially emergency situation the scan was to be delayed until after the weekend, which proved to be too late due to the fact that Mrs Woods died on Saturday 18th April 2015. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a specific application procedure for urgent CT scans

    Wider context from the report

    “(1) The NHS Trust does not have facilities for routine CT scans to be carried out during weekends (2) If an urgent CT scans are necessary a specific application procedure has to be put in place (3) In this case despite the requirements for an urgent scan to be undertaken in a potentially emergency situation the scan was to be delayed until after the weekend, which proved to be too late due to the fact that Mrs Woods died on Saturday 18th April 2015. ”
    Open source report

    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

    Existing out-of-hours CT access procedures and consultant escalation arrangements are considered sufficient for obtaining urgent scans when clinically required.

    Verbatim wording from the response

    “Without rehearsing my response, I am happy to assure you that there is sound reasoning behind our procedure. Patients fall under the care of consultants, but spend more time being actively treated by junior doctors. To ensure that patients are appropriately escalated for treatment of a worsening condition (in the full knowledge of the treating consultant) it is necessary to ensure that a consultant is aware when a patient is to be sent for a CT scan at all times. On weekdays when consultants are more readily available on-site within the Trust these referrals are less noticeable than out of hours or on weekends, but the procedure is always in place.”

    Source location

    sandra-wood-Response
    Page 2 · response
    Published 12 February 2016

    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

    The Trust disputes that weekend CT facilities are unavailable, stating emergency scans are provided without numerical restriction based on clinical need.

    Verbatim wording from the response

    “1) The NHS Trust does not have facilities for routine CT scans to be carried out during weekends.”

    Source location

    sandra-wood-Response
    Page 1 · response
    Published 12 February 2016

    Open published response

  8. Mid Kent and Medway

    AI-generated summary

    Christine McNamara · 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

    Christine McNamara was admitted for an elective ERCP, developed symptoms of bowel perforation, deteriorated despite treatment and died at Maidstone Hospital on 27 February 2015. The concerns identified were the absence of a pathway or guideline for post-ERCP complications and limitations on out-of-hours radiography referrals and surgical consultant cover.

    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of a surgical consultant on call from Maidstone during the working week

    Wider context from the report

    “(2)Out of hours radiography can only be referred on a consultant to consultant basis. There is no surgical consultant on call from Maidstone during the working week although there is a surgical consultant at Tunbridge Wells ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a pathway or guideline for post-ERCP patients who develop complications

    Wider context from the report

    “(1) It was established during the inquest that there was no pathway or guideline in place for post ERCP patients who develop complications ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Restriction of out-of-hours radiography referrals to consultant-to-consultant referral

    Wider context from the report

    “(2)Out of hours radiography can only be referred on a consultant to consultant basis. There is no surgical consultant on call from Maidstone during the working week although there is a surgical consultant at Tunbridge Wells ”
    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

    Implement a pathway for managing suspected post-endoscopy complications, perforations or leaks.

    Verbatim wording from the response

    “1) It was established during the inquest that there was no pathway or guideline in place for post ERCP patients who develop complications”

    Source location

    2015-0436-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 1 · response
    Published 16 November 2015

    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

    Require consultant-to-consultant referrals for out-of-hours radiology to ensure consultant involvement in treatment decisions.

    Verbatim wording from the response

    “Out of hours, junior doctors manage the immediate treatment of patients – escalating patients for additional investigations and/or procedures where necessary. In the past we have had instances where junior doctors were escalating the treatment of unwell/seriously unwell patients without consultant input. This resulted in consultants not being adequately involved in the treatment decisions of their patients, so to resolve this we introduced the consultant to consultant referral – thereby ensuring there is always adequate consideration of all treatment options.”

    Source location

    2015-0436-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 2 · response
    Published 16 November 2015

    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 implemented pathway after six months to determine whether staff require further clarity.

    Verbatim wording from the response

    “We are committed to ensuring that this pathway successfully addresses the potential issues regarding the appropriate escalation of unwell patients at all times – wherever they are within the Trust, and on whichever site. To ensure that the pathway adequately addresses the issues as intended, we will allow an initial period of 6 months for the pathway to become embedded, before conducting a full review (scheduled for October 2016) to consider whether any further clarity is required by our staff.”

    Source location

    2015-0436-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 1 · response
    Published 16 November 2015

    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

    The implemented post-endoscopy complication pathway is considered sufficient to address escalation concerns across Trust sites.

    Verbatim wording from the response

    “Our Medical Director discussed the issues raised in your report with representatives from the medical and surgical teams, and a new pathway (The Pathway for suspected post-endoscopy complication, perforation or leak) was devised to provide clear guidance to all staff on how to manage patients who have undergone endoscopic surgery. The pathway was implemented in January 2016, and a copy of the pathway is enclosed for your information.”

    Source location

    2015-0436-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 1 · response
    Published 16 November 2015

    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 consultant general surgeon is always on call and accessible, although weekday cover is predominantly based at Tunbridge Wells.

    Verbatim wording from the response

    “I want to start by assuring you that there is always a consultant general surgeon on call at all times and they can always be accessed by contacting switchboard – in the event a junior member of staff does not know who is on call, switchboard has a list and can direct them as appropriate.”

    Source location

    2015-0436-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 1 · response
    Published 16 November 2015

    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

    The consultant-to-consultant out-of-hours radiology referral policy is considered clinically justified and ensures adequate consideration of treatment options.

    Verbatim wording from the response

    “I appreciate that, taken out of context, the need for a consultant to consultant referral for radiology out of hours can seem onerous, but I want to assure you that there are sound clinical reasons underlying the policy.”

    Source location

    2015-0436-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
    Page 2 · response
    Published 16 November 2015

    Open published response

  9. Mid Kent and Medway

    AI-generated summary

    Peter Franklin · 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

    Peter Franklin, who had longstanding mental health difficulties and increasingly frequent hospital attendances, died after jumping from a motorway bridge following an attempted jump earlier that day. The concerns included unclear communication about whether a referral, advice or assessment was required, relevant information not being passed on, and delays in sharing information with his GP.

    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Confusion and lack of clarity in terminology for out-of-hours CRISIS team calls

    Wider context from the report

    “(1) There was confusion in the terminology used between nursing staff or doctors and the CRISIS team when out of hours calls were made such that it was not clear between parties whether a referral, advice or assessment was sought. ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the CRISIS team to provide relevant information or advice to referring parties

    Wider context from the report

    “(2) Relevant information/advice was not provided by the CRISIS team to parties who had made referrals ”
    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 Maidstone and Tunbridge Wells NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in hospital and mental health trust documentation reaching GPs

    Wider context from the report

    “(3) Mr. Franklin’s GP would have initiated a multidisciplinary team meeting to address the increasing frequency of attendances at hospital had he been aware of the recent hospital admission, the subsequent involvement with the mental health team and the attendances at A&E. The documentation from both hospital and mental health trusts was subject of significant delays such that none of the letters to the GP sent by either trust from July onward arrive[d] with the GP before Mr. Franklin died ”
    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

    Implement the SMART Tool in the Emergency Department, finalise its design, incorporate it into the Junior Doctor Handbook, and use it with the Mental Health Trust.

    Verbatim wording from the response

    “Firstly I would like to address the issue of confusion in terminology 5(1). The use of a SMART Tool was discussed and agreed at the Emergency Directorate Clinical Governance meeting on 1st July 2014. It is being implemented from an Emergency Department perspective by Dr Bell, Consultant in A&E Medicine and Cliff Evans, Consultant Nurse. Once the design is finalised this will be incorporated into the Junior Doctor Handbook. A copy of the format is attached for your information. This will be used in conjunction with the Mental Health Trust.”

    Source location

    2014-0230-Response-by-Tunbridge-Wells-Hospital
    Page 1 · response
    Published 19 May 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 the Electronic Discharge Summary to improve timely information reaching patients’ GPs.

    Verbatim wording from the response

    “5 (3) In the matter of discharge summaries and timely information reaching the patients GPs, the Trust is working towards implementing the Electronic Discharge Summary in line with the rest of the Trust. This is being coordinated by the Head of IT and Information Governance. This will be in place by October 2014. In the meantime all paper discharge summaries are signed and sent by post.”

    Source location

    2014-0230-Response-by-Tunbridge-Wells-Hospital
    Page 2 · response
    Published 19 May 2014

    Open published response
Back to top

Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

78%
78%All other recipients 58%
0%100%

How actions were described at the time

This respondent
57%22%21%
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