10 Feb 2026 Barbara Wingate · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 1 Failure to provide timely appropriate community care packages or alternative placements for medically fit patients View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Recommission the Integrated Care and Reablement Service to increase community health bed capacity and support acute-care discharge.
View source
Action
Establish a dedicated brokerage team to source care for people ready for discharge from hospital or community settings.
View source
Action
Commission eight assessment beds for people awaiting discharge who need therapy to regain independence before returning home.
View source
Action
Introduce 24-hour care-at-home services for people with high needs to return home safely where appropriate.
View source
Action
Progress governance processes to develop a new 80-bed care home addressing longer-term structural capacity constraints.
View source
Action
Recruit an independent commissioner to identify provider barriers to accepting discharged patients and support increased complex-needs residential and nursing capacity.
View source See 3 more actions
×
AI-generated summary
Barbara Wingate · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Barbara Wingate, a 71-year-old woman, fell at home on 18 May 2025, sustained multiple pelvic fractures, suffered a cardiac arrest and died on 21 May 2025 following multiple organ failure. The inquest identified avoidable delays in diagnosing and treating her pelvic fractures. The report also raised concerns about emergency department capacity, delayed discharge of medically fit patients, and insufficient timely community care or alternative placements, creating risks for other critically ill patients.
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 Medway Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely appropriate community care packages or alternative placements for medically fit patients
Wider context from the report “Evidence heard at the inquest revealed that the resuscitation department where Mrs Wingate should have been admitted was full and the evidence indicated that this was and is almost a daily occurrence at the Trust . The court heard that the main issue is trying to discharge a patient to a suitable area in the hospital to free up a cubicle or bay in the resuscitation department. This in turn is due to beds being occupied by patients who are medically fit to be discharged . On any given day the court heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital.
The court heard that the main delay is in discharging patients to appropriate settings or placements and the Trust have taken all steps they can internally to improve the flow of patients through the hospital. From the evidence it would appear that those responsible for providing care in the community including both the social care providers and the community healthcare providers are not providing either timely appropriate care packages in the patient's home or a bed in an alternative placement be that a nursing home or residential home placement . The evidence suggested that where patients were self funding the delays in discharge were less acute.
This means patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illnesses themselves which could lead to their own death but are also blocking beds which are needed to treat patients who require acute care . This is leading to patients being kept longer in the emergency department and reducing available space to receive new critically ill patients . Both of these options can lead to death as seen in this case and there is clearly a risk of death for others requiring clinical care in an acute hospital.
” Open source report
×
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 Recommission the Integrated Care and Reablement Service to increase community health bed capacity and support acute-care discharge.
Verbatim wording from the response “A range of actions have been implemented or are in progress these are:” Source location Response from Medway Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a dedicated brokerage team to source care for people ready for discharge from hospital or community settings.
Verbatim wording from the response “The Council has established a dedicated brokerage team focused solely on sourcing care for individuals ready to be discharged from hospital or community settings.” Source location Response from Medway Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission eight assessment beds for people awaiting discharge who need therapy to regain independence before returning home.
Verbatim wording from the response “The Council has commissioned eight assessment beds for individuals ready for discharge but requiring further therapy to support independence before returning home.” Source location Response from Medway Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce 24-hour care-at-home services for people with high needs to return home safely where appropriate.
Verbatim wording from the response “A range of actions have been implemented or are in progress these are:” Source location Response from Medway Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress governance processes to develop a new 80-bed care home addressing longer-term structural capacity constraints.
Verbatim wording from the response “Medway Council is progressing through governance processes to develop a new 80-bed care home, recognising ongoing system challenges. While a longer-term intervention, this reflects the Council’s seriousness in addressing structural capacity constraints” Source location Response from Medway Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit an independent commissioner to identify provider barriers to accepting discharged patients and support increased complex-needs residential and nursing capacity.
Verbatim wording from the response “The Council has recruited an independent commissioner to work with care providers to understand barriers to accepting discharged patients and to support increased residential and nursing home capacity, particularly for those with complex needs.” Source location Response from Medway Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discharge delays cannot be attributed solely to adult social care or community health services because they arise from interdependent system-wide factors.
Verbatim wording from the response “At any given time, it would be erroneous to conclude delays in hospital discharge can be attributed solely to adult social care or community health services. Evidence from across Medway demonstrates that delays arise from a range of interdependent factors across the health and social care system. These include:” Source location Response from Medway Council
Open published response
10 Feb 2026 Liam Andrew SUTTON · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 2 Delays in arranging timely appropriate community care packages or alternative placements for medically fit patients View source Failure to transfer patients from the emergency resuscitation area to suitable higher-acuity beds in a timely manner View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 8
Action
Create a dedicated brokerage team to source care for people ready for discharge from hospital and community health settings.
View source
Action
Introduce 24-hour home care for people with high care and support needs where returning home is safe and appropriate.
View source
Action
Investigate private providers’ barriers to accepting discharge-ready residents and identify ways to increase complex-needs residential and nursing capacity.
View source
Action
Commission eight assessment beds to provide therapy and support independence for people awaiting discharge home.
View source
Action
Recruit an independent commissioner to engage private care providers about hospital discharge capacity.
View source
Action
Progress governance approval to develop an 80-bed care home addressing longer-term capacity constraints.
View source
Action
Appoint a system-wide hospital discharge care coordinator to provide strategic oversight, coordination and escalation across organisational boundaries.
View source
Action
Recommission the Integrated Care and Reablement Service to increase community health bed capacity for hospital discharge.
View source See 5 more actions
×
AI-generated summary
Liam Andrew SUTTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Liam Sutton became unconscious at home after discharge following a total knee replacement with increased opioid medication, and was subsequently treated for suspected opioid toxicity, pneumonia or sepsis, respiratory complications and acute kidney injury. After intensive care treatment involving ventilation and repeated extubation attempts, he suffered an unresuscitable cardiac arrest during reintubation and died. The principal concerns were prolonged occupancy of the emergency department resuscitation area and hospital bed-blocking linked to delays in discharge and access to appropriate community or care placements.
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 Medway Council; that does not assign responsibility.
PFD Monitor interpretation Delays in arranging timely appropriate community care packages or alternative placements for medically fit patients
Wider context from the report “The court heard in the inquest revealed that the resuscitation department where Mr Sutton was admitted was busy and the evidence indicated that this was and is almost a daily occurrence at the Trust. Mr Sutton remained in the Emergency department resuscitation area for longer than 24 hours and should instead have been transferred to a suitable bed in the hospital. The Intensivist who gave evidence was clear that he should have been transferred to the High Dependency/ Intensive Care department and that patients who are admitted in a timely manner have a much better chance of survival. This also means that bays in the resuscitation department are not free to admit or attend to new acutely ill patients arriving at the hospital.
The court heard that the main issue is trying to discharge a patient to a suitable area in the hospital to free up a cubicle or bay in the resuscitation department. This in turn is due to beds being occupied by patients who are medically fit to be discharged . On any given day we heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital .
The court heard that the main delay is in discharging patients to appropriate settings or placements and the Trust have taken all steps they can internally to improve the flow of patients through the hospital. From the evidence the court heard it would appear that those responsible for providing care in the community including both the social care providers and the community healthcare providers are not providing either timely appropriate care packages in the patient's home or a bed in an alternative placement be that a nursing home or residential home placement . The evidence suggested that where patients were self funding the delays in discharge were less acute.
This means patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illnesses themselves which could lead to their own death but are also blocking beds which are needed to treat patients who require acute care in a suitable setting. This is leading to patients being kept longer in the emergency department and reducing available space to receive new critically ill patients. Both of these options can lead to death and there is clearly a risk of death for others requiring clinical care in an acute hospital
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Medway Council; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer patients from the emergency resuscitation area to suitable higher-acuity beds in a timely manner
Wider context from the report “The court heard in the inquest revealed that the resuscitation department where Mr Sutton was admitted was busy and the evidence indicated that this was and is almost a daily occurrence at the Trust. Mr Sutton remained in the Emergency department resuscitation area for longer than 24 hours and should instead have been transferred to a suitable bed in the hospital . The Intensivist who gave evidence was clear that he should have been transferred to the High Dependency/ Intensive Care department and that patients who are admitted in a timely manner have a much better chance of survival . This also means that bays in the resuscitation department are not free to admit or attend to new acutely ill patients arriving at the hospital.
The court heard that the main issue is trying to discharge a patient to a suitable area in the hospital to free up a cubicle or bay in the resuscitation department. This in turn is due to beds being occupied by patients who are medically fit to be discharged. On any given day we heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital.
The court heard that the main delay is in discharging patients to appropriate settings or placements and the Trust have taken all steps they can internally to improve the flow of patients through the hospital. From the evidence the court heard it would appear that those responsible for providing care in the community including both the social care providers and the community healthcare providers are not providing either timely appropriate care packages in the patient's home or a bed in an alternative placement be that a nursing home or residential home placement. The evidence suggested that where patients were self funding the delays in discharge were less acute.
This means patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illnesses themselves which could lead to their own death but are also blocking beds which are needed to treat patients who require acute care in a suitable setting. This is leading to patients being kept longer in the emergency department and reducing available space to receive new critically ill patients. Both of these options can lead to death and there is clearly a risk of death for others requiring clinical care in an acute hospital
” Open source report
×
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 Create a dedicated brokerage team to source care for people ready for discharge from hospital and community health settings.
Verbatim wording from the response “Sourcing Care: Medway Council has created a dedicated brokerage team to find care for people ready to be discharged from hospital and community health settings. This means that the team is not balancing the need to source care for people in the community at the same time.” Source location Response from Medway Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce 24-hour home care for people with high care and support needs where returning home is safe and appropriate.
Verbatim wording from the response “Commissioning action: The council has introduced 24-hour care at home to enable people who have high care and support needs to go home, rather than to a care home where it is safe and appropriate.” Source location Response from Medway Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate private providers’ barriers to accepting discharge-ready residents and identify ways to increase complex-needs residential and nursing capacity.
Verbatim wording from the response “Market engagement: The council has recruited an independent commissioner to work with private care providers to better understand why they are not accepting residents who are ready to be discharged from hospital, to determine how we can increase residential and nursing home capacity, particularly for people with complex needs.” Source location Response from Medway Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission eight assessment beds to provide therapy and support independence for people awaiting discharge home.
Verbatim wording from the response “Commissioning action: The council has commissioned 8 assessment beds to enable people who are ready to be discharged but not quite ready to go home to receive therapy and support them to independence.” Source location Response from Medway Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit an independent commissioner to engage private care providers about hospital discharge capacity.
Verbatim wording from the response “Market engagement: The council has recruited an independent commissioner to work with private care providers to better understand why they are not accepting residents who are ready to be discharged from hospital, to determine how we can increase residential and nursing home capacity, particularly for people with complex needs.” Source location Response from Medway Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress governance approval to develop an 80-bed care home addressing longer-term capacity constraints.
Verbatim wording from the response “Long term capacity development: Medway Council is progressing through the governance process to develop an 80-bed care home, recognising ongoing system challenges. While a longer-term intervention, this reflects the Council’s seriousness in addressing structural capacity constraints.” Source location Response from Medway Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint a system-wide hospital discharge care coordinator to provide strategic oversight, coordination and escalation across organisational boundaries.
Verbatim wording from the response “System Leadership: A single care co-ordinator for hospital discharge has been appointed to operate on a system basis and reports directly to the Director of Adult Social Services (DASS) providing strategic oversight, coordination and escalation across organisational boundaries and to the Chief Operating Officer at Medway Foundation Trust from an operational perspective.” Source location Response from Medway Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recommission the Integrated Care and Reablement Service to increase community health bed capacity for hospital discharge.
Verbatim wording from the response “Commissioning action: The council has recommissioned the Integrated Care and Reablement Service (ICRS). This will increase community health bed capacity to support discharge from acute care.” Source location Response from Medway Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discharge delays are not wholly attributable to adult social care or community health services; they result from interdependent whole-system factors.
Verbatim wording from the response “At any given time, delays in discharge are not wholly attributable to adult social care or community health services. Evidence across Medway demonstrates that delays arise from a combination of interdependent factors across the health and social care system. These include acute hospital internal flow, bed availability, discharging planning processes, clinical decision making and escalation arrangements, alongside capacity constraints in community and social care provision.
While the acute trust has implemented a range of measures to improve patient flow, it would not be accurate to conclude that all possible internal actions have been exhausted. Improvements continue at a system interface level, and this position is recognised across partners and underpins the ongoing whole system oversight arrangements described below.” Source location Response from Medway Council
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations