10 Feb 2026 Barbara Wingate · Prevention of Future Deaths report Kent and Medway
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Concerns raised 1 Failure to provide timely appropriate community care packages or alternative placements for medically fit patients View source
Responses linked to these concerns
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AI-generated summary
Barbara Wingate · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Barbara Wingate, a 71-year-old woman, fell at home on 18 May 2025, sustained multiple pelvic fractures, suffered a cardiac arrest and died on 21 May 2025 following multiple organ failure. The inquest identified avoidable delays in diagnosing and treating her pelvic fractures. The report also raised concerns about emergency department capacity, delayed discharge of medically fit patients, and insufficient timely community care or alternative placements, creating risks for other critically ill patients.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely appropriate community care packages or alternative placements for medically fit patients
Wider context from the report “Evidence heard at the inquest revealed that the resuscitation department where Mrs Wingate should have been admitted was full and the evidence indicated that this was and is almost a daily occurrence at the Trust . The court heard that the main issue is trying to discharge a patient to a suitable area in the hospital to free up a cubicle or bay in the resuscitation department. This in turn is due to beds being occupied by patients who are medically fit to be discharged . On any given day the court heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital.
The court heard that the main delay is in discharging patients to appropriate settings or placements and the Trust have taken all steps they can internally to improve the flow of patients through the hospital. From the evidence it would appear that those responsible for providing care in the community including both the social care providers and the community healthcare providers are not providing either timely appropriate care packages in the patient's home or a bed in an alternative placement be that a nursing home or residential home placement . The evidence suggested that where patients were self funding the delays in discharge were less acute.
This means patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illnesses themselves which could lead to their own death but are also blocking beds which are needed to treat patients who require acute care . This is leading to patients being kept longer in the emergency department and reducing available space to receive new critically ill patients . Both of these options can lead to death as seen in this case and there is clearly a risk of death for others requiring clinical care in an acute hospital.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand access to short-term community rehabilitation beds to improve onward flow for patients no longer requiring acute inpatient care.
Verbatim wording from the response “3. Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing transfer delays – work is underway to expand access to short-term community rehabilitation beds improving onward flow for patients who no longer need acute inpatient care. A new bed-coordination (brokerage) function will be operational by quarter three of 2026 ahead of winter with clear accountability for timely allocation and progress monitored monthly through ICB assurance routes.” Source location 2026-0088 - Response from Kent and Medway ICB
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Medway Care Transfer Hub as the single coordination and escalation point for new residential and nursing placements, with weekly performance reporting to the ICB.
Verbatim wording from the response “The Medway Care Transfer Hub now acts as the single coordination and escalation point for the Local Authority and Health to support patients requiring new residential or nursing placements. This ensures consistent, person-centred decision making and removes delays associated with variable processes. The Hub provides weekly reports to the ICB on performance, issues, and escalations.” Source location 2026-0088 - Response from Kent and Medway ICB
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 Increase short-term home-care capacity so more patients can be safely discharged with necessary support.
Verbatim wording from the response “Over the last six months we have taken coordinated actions with Medway Council, Medway Foundation NHS Trust (MFT) and wider system partners to make several improvements to the main, nationally agreed pathways, which are used by the hospital for discharge. The pathways have been developed to address individual patient need and circumstances:” Source location 2026-0088 - Response from Kent and Medway ICB
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 bed-coordination brokerage function for timely allocation of short-term community rehabilitation beds by the third quarter of 2026.
Verbatim wording from the response “3. Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing transfer delays – work is underway to expand access to short-term community rehabilitation beds improving onward flow for patients who no longer need acute inpatient care. A new bed-coordination (brokerage) function will be operational by quarter three of 2026 ahead of winter with clear accountability for timely allocation and progress monitored monthly through ICB assurance routes.” Source location 2026-0088 - Response from Kent and Medway ICB
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 Increase short-term care-at-home capacity to enable safe discharge with necessary support, overseen through the Medway System Discharge Group.
Verbatim wording from the response “2. Expanding the Home First/short-term support capacity (Pathway 1, Discharge home with short-term support) – capacity for short-term care at home has been increased so more people can leave hospital safely with the necessary support. Oversight of capacity, flow and performance is provided through the Medway System Discharge Group, a local MDT approach supporting discharge.” Source location Response from Kent and Medway Integrated Care Board
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 Operate the Medway Care Transfer Hub as the single coordination and escalation point for new residential or nursing placements, with weekly performance reporting to the ICB.
Verbatim wording from the response “The Medway Care Transfer Hub now acts as the single coordination and escalation point for the Local Authority and Health to support patients requiring new residential or nursing placements. This ensures consistent, person-centred decision making and removes delays associated with variable processes. The Hub provides weekly reports to the ICB on performance, issues, and escalations.” Source location Response from Kent and Medway Integrated Care Board
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 Expand access to short-term community rehabilitation beds to improve onward flow for patients no longer requiring acute inpatient care.
Verbatim wording from the response “3. Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing transfer delays – work is underway to expand access to short-term community rehabilitation beds improving onward flow for patients who no longer need acute inpatient care. A new bed-coordination (brokerage) function will be operational by quarter three of 2026 ahead of winter with clear accountability for timely allocation and progress monitored monthly through ICB assurance routes.” Source location Response from Kent and Medway Integrated Care Board
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 bed-coordination brokerage function for timely allocation of short-term community rehabilitation beds by the third quarter of 2026.
Verbatim wording from the response “3. Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing transfer delays – work is underway to expand access to short-term community rehabilitation beds improving onward flow for patients who no longer need acute inpatient care. A new bed-coordination (brokerage) function will be operational by quarter three of 2026 ahead of winter with clear accountability for timely allocation and progress monitored monthly through ICB assurance routes.” Source location Response from Kent and Medway Integrated Care Board
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
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Liam Andrew SUTTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Liam Sutton became unconscious at home after discharge following a total knee replacement with increased opioid medication, and was subsequently treated for suspected opioid toxicity, pneumonia or sepsis, respiratory complications and acute kidney injury. After intensive care treatment involving ventilation and repeated extubation attempts, he suffered an unresuscitable cardiac arrest during reintubation and died. The principal concerns were prolonged occupancy of the emergency department resuscitation area and hospital bed-blocking linked to delays in discharge and access to appropriate community or care placements.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Kent and Medway Integrated Care Board; 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 NHS Kent and Medway Integrated Care Board; 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 Expand access to short-term community rehabilitation beds to improve onward flow for patients no longer requiring acute inpatient care.
Verbatim wording from the response “Over the last six months we have taken coordinated actions with Medway Council, Medway Foundation NHS Trust (MFT) and wider system partners to make several improvements to the main, nationally agreed pathways, which are used by the hospital for discharge. The pathways have been developed to address individual patient need and circumstances:” Source location Response from Kent and Medway ICB
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 Operate the Medway Care Transfer Hub as the single coordination and escalation point for new residential and nursing placements, with weekly performance reporting.
Verbatim wording from the response “The Medway Care Transfer Hub now acts as the single coordination and escalation point for the Local Authority and Health to support patients requiring new residential or nursing placements. This ensures consistent, person-centred decision making and removes delays associated with variable processes. The Hub provides weekly reports to the ICB on performance, issues, and escalations.” Source location Response from Kent and Medway ICB
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 bed-coordination brokerage function for timely allocation of short-term community rehabilitation beds by the third quarter of 2026.
Verbatim wording from the response “3. Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing transfer delays – work is underway to expand access to short-term community rehabilitation beds improving onward flow for patients who no longer need acute inpatient care. A new bed-coordination (brokerage) function will be operational by quarter three of 2026 ahead of winter with clear accountability for timely allocation and progress monitored monthly through ICB assurance routes.” Source location Response from Kent and Medway ICB
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 Increase short-term home-care capacity so patients can leave hospital safely with necessary support.
Verbatim wording from the response “Over the last six months we have taken coordinated actions with Medway Council, Medway Foundation NHS Trust (MFT) and wider system partners to make several improvements to the main, nationally agreed pathways, which are used by the hospital for discharge. The pathways have been developed to address individual patient need and circumstances:” Source location Response from Kent and Medway ICB
Open published response
7 Feb 2025 Ella Louise Murray · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 6 Failure to take urgent safeguarding steps to remove children from an unsafe family home View source Delays in convening multi-agency safeguarding meetings View source Lack of shared access to safeguarding records across agencies View source Inadequate assessment of risk to children presenting with safeguarding and mental health concerns View source Failure to provide agencies with access to all relevant cross-sector safeguarding information View source Lack of a mechanism to convene urgent multi-agency safeguarding meetings View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Ella Louise Murray · 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
Ella Louise Murray was 13 years old when she died at Kings College hospital on 15 November 2023 following an episode of hanging, after a period of self-harm, suicidal ideation and deteriorating mental health. The report raised concerns about the adequacy of her risk assessment and the failure to take urgent protective action, including removing her from home or convening an urgent multi-agency response. It also identified the lack of shared information and records across health, social care and education services.
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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to take urgent safeguarding steps to remove children from an unsafe family home
Wider context from the report “(1)During the course of the inquest it became clear that Ella was a child in a complex family situation and showing signs of deterioration of her mental health. Her school had raised concerns about her with social services and taken steps to make sure she was seen by healthcare professionals when she indicated to staff at school she wanted to end her life on 13 November 2023. She was assessed by mental health nursing staff and accepted to the caseload of the Intensive Home Treatment Team. She was seen the following day and told the staff nurse who saw her that she was frightened of her stepfather and had run away from home barefoot and police called but she was brought back home by her mother who “grabbed her face” the morning she was seen. She told the nurse that she did not want to be in the family home and would rather go to prison and would harm herself or others is she had to stay at home.
(2) This disclosure led to the nurse making a Safeguarding Referral but this was made after she left Ella’s home and no urgent steps were taken to remove Ella either to a hospital bed or to ask social services to consider if she should be removed from the family home . Her school had raised concerns about her and she herself had indicated she wished to end her life. Evidence heard at the inquest was that this was the procedure in place and there is no shared access to records for all agencies and no way to convene an urgent multi-agency meeting to determine if Ella was safe to remain at home. Had steps been taken to share information between her school, social services and the mental health providers when she attend the emergency department on 13 November 2023 or early the following day rather than leave her at home she may have been removed from her home and may still be alive today.
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in convening multi-agency safeguarding meetings
Wider context from the report “(3) Whilst there were concerns about the level of risk assessment undertaken on 14 November 2023 senior staff at the Trust gave evidence that she did not meet the criteria for admission to a hospital bed. This was difficult to reconcile with the documentary evidence as she was clearly crying out for help and her school had recognised this. No one agency involved had access to all the relevant information and concerns about Ella across the health, social care and education arenas. Evidence given suggested that shared records would assist but the ability to respond to urgent concerns would require a system change.
(4)It was brought to the court’s attention that the new Children’s Wellbeing and Schools bill includes a duty to share information to promote safeguarding. In addition the local authority may convene a strategy meeting under s47 of the Children Act 1989 although the speed of convening a meeting would depend on availability and would obviously not be as swift as for example attending an accident and emergency department . If a multiagency meeting had been convened this may have prevented Ella’s death and such action may reduce the risk of death for other children being in a similar position.
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of shared access to safeguarding records across agencies
Wider context from the report “(1)During the course of the inquest it became clear that Ella was a child in a complex family situation and showing signs of deterioration of her mental health. Her school had raised concerns about her with social services and taken steps to make sure she was seen by healthcare professionals when she indicated to staff at school she wanted to end her life on 13 November 2023. She was assessed by mental health nursing staff and accepted to the caseload of the Intensive Home Treatment Team. She was seen the following day and told the staff nurse who saw her that she was frightened of her stepfather and had run away from home barefoot and police called but she was brought back home by her mother who “grabbed her face” the morning she was seen. She told the nurse that she did not want to be in the family home and would rather go to prison and would harm herself or others is she had to stay at home.
(2) This disclosure led to the nurse making a Safeguarding Referral but this was made after she left Ella’s home and no urgent steps were taken to remove Ella either to a hospital bed or to ask social services to consider if she should be removed from the family home. Her school had raised concerns about her and she herself had indicated she wished to end her life. Evidence heard at the inquest was that this was the procedure in place and there is no shared access to records for all agencies and no way to convene an urgent multi-agency meeting to determine if Ella was safe to remain at home. Had steps been taken to share information between her school, social services and the mental health providers when she attend the emergency department on 13 November 2023 or early the following day rather than leave her at home she may have been removed from her home and may still be alive today.
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate assessment of risk to children presenting with safeguarding and mental health concerns
Wider context from the report “(3) Whilst there were concerns about the level of risk assessment undertaken on 14 November 2023 senior staff at the Trust gave evidence that she did not meet the criteria for admission to a hospital bed. This was difficult to reconcile with the documentary evidence as she was clearly crying out for help and her school had recognised this. No one agency involved had access to all the relevant information and concerns about Ella across the health, social care and education arenas. Evidence given suggested that shared records would assist but the ability to respond to urgent concerns would require a system change.
(4)It was brought to the court’s attention that the new Children’s Wellbeing and Schools bill includes a duty to share information to promote safeguarding. In addition the local authority may convene a strategy meeting under s47 of the Children Act 1989 although the speed of convening a meeting would depend on availability and would obviously not be as swift as for example attending an accident and emergency department. If a multiagency meeting had been convened this may have prevented Ella’s death and such action may reduce the risk of death for other children being in a similar position.
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide agencies with access to all relevant cross-sector safeguarding information
Wider context from the report “(3) Whilst there were concerns about the level of risk assessment undertaken on 14 November 2023 senior staff at the Trust gave evidence that she did not meet the criteria for admission to a hospital bed. This was difficult to reconcile with the documentary evidence as she was clearly crying out for help and her school had recognised this. No one agency involved had access to all the relevant information and concerns about Ella across the health, social care and education arenas. Evidence given suggested that shared records would assist but the ability to respond to urgent concerns would require a system change.
(4)It was brought to the court’s attention that the new Children’s Wellbeing and Schools bill includes a duty to share information to promote safeguarding. In addition the local authority may convene a strategy meeting under s47 of the Children Act 1989 although the speed of convening a meeting would depend on availability and would obviously not be as swift as for example attending an accident and emergency department. If a multiagency meeting had been convened this may have prevented Ella’s death and such action may reduce the risk of death for other children being in a similar position.
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism to convene urgent multi-agency safeguarding meetings
Wider context from the report “(1)During the course of the inquest it became clear that Ella was a child in a complex family situation and showing signs of deterioration of her mental health. Her school had raised concerns about her with social services and taken steps to make sure she was seen by healthcare professionals when she indicated to staff at school she wanted to end her life on 13 November 2023. She was assessed by mental health nursing staff and accepted to the caseload of the Intensive Home Treatment Team. She was seen the following day and told the staff nurse who saw her that she was frightened of her stepfather and had run away from home barefoot and police called but she was brought back home by her mother who “grabbed her face” the morning she was seen. She told the nurse that she did not want to be in the family home and would rather go to prison and would harm herself or others is she had to stay at home.
(2) This disclosure led to the nurse making a Safeguarding Referral but this was made after she left Ella’s home and no urgent steps were taken to remove Ella either to a hospital bed or to ask social services to consider if she should be removed from the family home. Her school had raised concerns about her and she herself had indicated she wished to end her life. Evidence heard at the inquest was that this was the procedure in place and there is no shared access to records for all agencies and no way to convene an urgent multi-agency meeting to determine if Ella was safe to remain at home . Had steps been taken to share information between her school, social services and the mental health providers when she attend the emergency department on 13 November 2023 or early the following day rather than leave her at home she may have been removed from her home and may still be alive today.
” Open source report
5 Mar 2024 Kerri Louise Mothersole · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 2 Failure to make private-provider imaging available through the central imaging system View source Failure to provide community ultrasound reports and images to treating clinicians View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kerri Louise Mothersole · 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
Kerri Louise Mothersole, a 44-year-old woman, died on 20 August 2022 after developing endometrial cancer with brain metastases. Her diagnosis was delayed, including because an earlier ultrasound report and associated images were not provided to treating clinicians or uploaded to hospital clinical notes, and community imaging was not available on the central imaging system.
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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to make private-provider imaging available through the central imaging system
Wider context from the report “(1) The two reports from HEM Clinical Ultrasound Ltd on 28 June 2021 and 1 July 2021 and any images associated with the reports were not provided to any of the deceased's treating clinicians. Only the second report from 1 July 2021 was sent to her General Practitioner and not the first report from 28 June 2021. Neither report was uploaded to her clinical notes at Medway Maritime hospital or Maidstone hospital. Had the images and the reports been available to her treating clinicians then a more urgent referral would have been warranted by her General Practitioner and she may have been investigated and treated at a much earlier stage.
(2) The court heard that most of Kent have a system whereby imaging taken can be seen at more than one Trust and is even linked to tertiary referral centres in London. The system used
was referred to as the PACS system. Clinicians told the court that they could look up images for their patients taken at another hospital and this would impact on their decision making for a patient. Images taken in the community by private providers are not uploaded to the system but can be requested however this relies upon knowing that there were any images to access in the first instance.
(3) The managing partner at HEM Clinical Ultrasound Ltd gave evidence that she had been requesting that the imaging they took be made available on the central system. She was unable to explain why this had not been requested or set up or commissioned by the Integrated Care Board. All gave evidence that the lack of imaging being available meant that issues could be missed and this created a risk to patients, which at its extreme would include a risk of future deaths.
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide community ultrasound reports and images to treating clinicians
Wider context from the report “(1) The two reports from HEM Clinical Ultrasound Ltd on 28 June 2021 and 1 July 2021 and any images associated with the reports were not provided to any of the deceased's treating clinicians. Only the second report from 1 July 2021 was sent to her General Practitioner and not the first report from 28 June 2021. Neither report was uploaded to her clinical notes at Medway Maritime hospital or Maidstone hospital. Had the images and the reports been available to her treating clinicians then a more urgent referral would have been warranted by her General Practitioner and she may have been investigated and treated at a much earlier stage.
(2) The court heard that most of Kent have a system whereby imaging taken can be seen at more than one Trust and is even linked to tertiary referral centres in London. The system used
was referred to as the PACS system. Clinicians told the court that they could look up images for their patients taken at another hospital and this would impact on their decision making for a patient. Images taken in the community by private providers are not uploaded to the system but can be requested however this relies upon knowing that there were any images to access in the first instance.
(3) The managing partner at HEM Clinical Ultrasound Ltd gave evidence that she had been requesting that the imaging they took be made available on the central system. She was unable to explain why this had not been requested or set up or commissioned by the Integrated Care Board. All gave evidence that the lack of imaging being available meant that issues could be missed and this created a risk to patients, which at its extreme would include a risk of future deaths.
” 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 the incident and diagnostic workflow, audit data-sharing systems, and produce and assess an options appraisal for process and IT integration improvements.
Verbatim wording from the response “2. To provide longer term assurance, and in acknowledgment of this matter, NHS Kent and Medway will examine potential changes where appropriate relating to IT integration. To support this, we will undertake a review of how the incident occurred and determine how the risk of this re-occurring can be reduced. This will include:” Source location Response from Kent and Medway
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 transitioning providers from individual PACS systems to a central PACS system, including integration of acute provider trusts.
Verbatim wording from the response “To address the concerns highlighted in the Regulation 28 Report, we can confirm that Kent and Medway have been moving away from individual PACS systems resident in each of our providers to a central PACS system. Procurement commenced in 2021, with the integration of acute provider trusts in September 2023.” Source location Response from Kent and Medway
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 first ultrasound report was inaccurate and should not have been sent to the patient’s GP.
Verbatim wording from the response “For information regarding this patient’s case, the ICB Patient Safety Team has requested that HEM Clinical Ultrasound complete a Serious Incident (SI) Investigation regarding the Coroner’s first concern. This concern notes that there were two ultrasound reports available, only one of which was initially sent to the patient’s GP. The provider has stated that that first report was inaccurate and should not have been sent to the patient’s GP.” Source location Response from Kent and Medway
Open published response
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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 GPs receive community diagnostic reports, assess them clinically, and decide whether referral to secondary care is required.
Verbatim wording from the response “Community diagnostics were introduced in the 2010s to improve access and reduce cost. However, no work was commissioned at the time to provide integration to GP or acute systems. The standard protocol is for community diagnostic providers to send reports (text-based), as opposed to the full diagnostics image, back to the GP that requested the investigation. The GP will then assess the report in the context of their holistic assessment of the patient and they make a clinical decision on whether to refer a patient to secondary care.” Source location Response from Kent and Medway
Open published response
Concerns raised 1 Insufficient availability of suitable specialist placements for autistic young adults at risk of self-harm or harm to others View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Benjamin Henry Hazelden · 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
Benjamin Henry Hazelden died at the scene on 11 February 2022 after he assaulted two staff members, ran to a nearby train station and was hit by a train. The report identified limited availability of suitable specialist placements for young adults with autism and risks of self-harm or harm to others; he was discharged home with increased support because no suitable specialist bed was available.
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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of suitable specialist placements for autistic young adults at risk of self-harm or harm to others
Wider context from the report “1. In the course of the hearing the evidence it was clear that young adults with autism who were at risk of self-harm as well as harm to others have very limited options in terms of placements where their needs can be met . A bespoke placement had been carefully created by those involved in Ben’s care but this had taken several months to arrange. This arrangement had worked well and all involved tried to make it a success and for quite some time it was. It was however recognised that there may come a time in the future when his risks to himself and others would mean an alternative placement would be needed.
2. When Ben’s risks to himself increased further there were no suitable beds available where he could be cared for in an environment which could meet his needs . He spent several days in an acute hospital bed despite being medically fit for discharge which although, essentially a place of safety, was totally unsuited to his needs. This stay continued whilst discussions ensued regarding where he should be placed. A bed in an acute psychiatric ward was considered but not deemed appropriate to meet his needs and as there were no specialist beds available he was discharged back to his home with increased support as the best option available . Had a bed been available in a specialist unit it is likely that he would not have died when he did.
3. In the evidence provided it became clear that a lot of units where a specialist bed may have been available had been closed in the past due to concerns about the level of care following a number of investigations. This has led to a system whereby locally and nationally there are limited options for those requiring care relating to both the management of autism and self-harm or harm to others, particularly when there is an urgent need for increased support . Whilst the inquest heard there were some counties who had specialist beds they were difficult to access as they were often full and places were not always available to meet urgent needs
” 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 Participate with Sussex and Surrey ICBs in scoping options for specialist inpatient beds for people with learning disabilities and autistic people.
Verbatim wording from the response “Kent and Medway ICB is currently involved in a project with colleagues in Sussex ICB and Surrey ICB to scope options for the provision of specialist in-patient beds for people with learning disability and for autistic people across the Kent, Surrey, and Sussex footprint. Commissioning specialist in-patient services across this broader geographical footprint provides critical mass of patient need and economies of scale which cannot be achieved by one ICB alone due to the reduced need for such services as a result of implementing national policy. PA Consulting, a private consulting firm, have been commissioned by Sussex ICB to develop and present proposals for specialist in-patient services by the end of March 2024 (Phase 1) for the three ICBs to consider and consult on with autistic people and other stakeholders (Phase 2) and implement collaboratively (Phase 3).” Source location Response from NHS Kent and Medway
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 One ICB cannot independently commission specialist inpatient services because reduced demand prevents achieving sufficient critical mass and economies of scale.
Verbatim wording from the response “Kent and Medway ICB is currently involved in a project with colleagues in Sussex ICB and Surrey ICB to scope options for the provision of specialist in-patient beds for people with learning disability and for autistic people across the Kent, Surrey, and Sussex footprint. Commissioning specialist in-patient services across this broader geographical footprint provides critical mass of patient need and economies of scale which cannot be achieved by one ICB alone due to the reduced need for such services as a result of implementing national policy. PA Consulting, a private consulting firm, have been commissioned by Sussex ICB to develop and present proposals for specialist in-patient services by the end of March 2024 (Phase 1) for the three ICBs to consider and consult on with autistic people and other stakeholders (Phase 2) and implement collaboratively (Phase 3).” Source location Response from NHS Kent and Medway
Open published response
Concerns raised 1 Insufficient nursing staffing capacity and resilience in the community mental health team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Benjamin James HART · 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
Benjamin Hart, aged 25, died by hanging at his mother’s home after contacting the Crisis team three times in the preceding two days and expressing hopelessness and suicidal feelings. The report describes limited contact with the community mental health team, a breakdown in his care-coordinator relationship, and no attempted contact before his death despite the team being notified. A principal concern was severe nursing-staff shortages, which left no capacity to allocate him a replacement care coordinator.
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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing staffing capacity and resilience in the community mental health team
Wider context from the report “The Trust had a shortfall of nursing staff in the Dover and Deal area at the time that Benjamin Hart was under the community mental health team such that although 16 nurses were required to run the service, the Trust only had 8 nurses employed at the time, 2 of whom were long term sick . This left a working complement of 6 nurses to cover the whole area, which required them to take on additional duties . There was no resilience within the team and therefore when the relationship between Ben and his care coordinator broke down there was no capacity within the team to allocate him another care coordinator .
Although the Trust has regrouped, reorganised and there has been some limited recruitment the shortfall endures ; the evidence given at the inquest being that this is a national issue but it is particularly difficult to recruit within this area of Kent
” Open source report
19 Feb 2023 Stefan Kluibenschadl · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 1 Lack of allocated case managers or key workers for autistic children and young people View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stefan Kluibenschadl · 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
Stefan Kluibenschadl was found hanging at home on 20 March 2022 and died in hospital on 26 March 2022. He had autism and had experienced a decline in mental health. The report raised concern that he did not have a case manager or key worker to help him and his family navigate available support services, and that many autistic young people may similarly lack access to such support.
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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of allocated case managers or key workers for autistic children and young people
Wider context from the report “1. During the course of the inquest reference was made to the National Institute for Clinical Excellence (NICE) guidance “Autistic Spectrum disorder in under 19s: support and management.” Published on 28 August 2013 and in particular paragraph 1.1.4 which states that “Local autism teams should ensure that every child or young person diagnosed with autism has a case manager or key worker to manage and coordinate treatment, care, support and transition to adult care in line with the NICE guideline on autism in children and young people (covering identification and diagnosis).” Stefan did not have a case manager or key worker.
2. I am unable to say if the lack of a case manager or key worker caused or contributed more than minimally to Stefan’s death but had one been available they may have been able to assist Stefan and his family to navigate the services available which in turn may have led to intervention which may have made a difference. I am prohibited from returning to a conclusion which comments on issues where there is no clear causal link with the death however the Coroner’s and Justice Act 2009 creates a duty on Coroners to report an issue which gives rise to a concern which may lead to future deaths.
3. I asked for further evidence on the provision of case managers/key workers in accordance with the NICE guidance after the inquest from North East London Foundation Trust and Kent and Medway Integrated Care Board. It is clear from the evidence provided that such a service is only provided to those under 19 years old who have both a learning disability and/or a diagnosis of autism and are at risk of admission to a mental health hospital or where there is a significant sudden deterioration in the community and the multi disciplinary team has not been responsive. The lowest level of service outlined in reply to the court indicated that referrals could be made to a key worker to sign post families not that they would have a key worker allocated to them. This sets the bar at a level which means a large number of young people with a learning disability and/or autism would not have a key worker nor would they be expected to have one .
4. In the evidence provided it was outlined that “Keyworkers will make sure that these children, young people and families get the right support at the right time. They will make sure that local systems are responsive to fully meeting the young people’s needs in a joined-up way and that whenever it is possible to provide care and treatment in the community with the right support this becomes the norm.” If every autistic child or young person had a key worker this would enable them or their family the opportunity to liaise with their key worker rather than having to try to navigate services themselves. This, in turn, may prevent others from encountering the issues faced by Stefan’s family and ultimately prevent future deaths.
” Open source report
Concerns raised 9 Exclusion of children with complex neurodevelopmental needs from required care and treatment View source Failure of Children with Disabilities services to assess children with high-risk behaviour View source Inadequate timely communication and follow-up action between agencies View source Inadequate support for families of children with rare diseases and behavioural difficulties View source Failure to offer psychosocial interventions for high-risk behaviour View source Diagnostic-only commissioning for children with autism and learning disabilities without an overt mental health diagnosis View source Lack of knowledge among service staff about available support View source Insufficient funding and replacement support for wrap-around home care View source Failure to implement suggested Care Education and Treatment Reviews View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Samuel Alban Stanley · 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
Samuel Alban Stanley died in hospital on 26 April 2020 from injuries sustained during an episode of high-risk behaviour related to his Prader-Willi syndrome. The report raised concerns about inadequate support for him and his family, limited access to appropriate services, and poor communication between agencies.
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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Exclusion of children with complex neurodevelopmental needs from required care and treatment
Wider context from the report “(5) It was clear at the hearing that locally Kent County Council had taken steps to change the way their services were delivered following Sammy’s death but it is predictable that a similar incident may arise in other areas if children with complex neurodevelopmental needs are excluded from accessing the care and treatment they require to keep them safe .
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of Children with Disabilities services to assess children with high-risk behaviour
Wider context from the report “(2) Evidence was given at the inquest that the social workers from Kent County Council were fully aware of Sammy’s high-risk behaviour and had on several occasions referred him to their Children with Disabilities team who refused to assess him . Sammy’s behaviour was also having an adverse impact on his three younger siblings. His mother had repeatedly reported that she could not keep Sammy safe without support and had sought assistance from state agencies, Charites and done as much as she possibly could herself. Social workers took steps to try to access support for his family to enable them to care for him but the way services were managed meant those involved had little knowledge of what was available. One social worker gave evidence that Sammy’s behaviour had escalated between August 2019 and January 2020 when he did not have access to support in the home. However, despite being aware that Sammy needed more support to provide wrap around care before and after the school day only very limited support was funded from the end of January 2020. When the advice was given for him to shield in March 2020, due to the Covid 19 pandemic, he now had to isolate and was without the supportive school environment yet no replacement support was provided despite the need being obvious.
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate timely communication and follow-up action between agencies
Wider context from the report “(4) The evidence at the inquest also revealed that communication between agencies involved in his short life was inadequate . It is possible that had information been shared in a timely manner and actions taken as a result then more support could have been provided to Sammy and his family. Had he, and his family, had more practical help and support this may have made a difference to his high-risk behaviour and ultimately his death.
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate support for families of children with rare diseases and behavioural difficulties
Wider context from the report “(1) Evidence given at the inquest by Professor ████████ from Great Ormond Street made it clear that the episodes of behavioural difficulties experienced by Sammy were inherently a part of his Prader Willi syndrome. He also indicated that it was not uncommon for the parents of children with behavioural difficulties associated with their underlying disease to inform him that they did not have adequate support . He opined that whilst the risk cannot be eliminated it could be managed through a combination of psychosocial intervention, sometimes with medication and care. He told the court that more support should be available to the families of children with rare diseases such as Prader Willi syndrome .
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to offer psychosocial interventions for high-risk behaviour
Wider context from the report “(3) There was evidence given that the mental health team at North East London Foundation Trust were also aware of Sammy’s high-risk behaviours. Support had been provided by a psychology student in the past and he had reportedly responded well to mindfulness therapy and the de-escalation techniques employed by his family. Psychosocial interventions were not offered by the Mental Health Trust and a Care Education and Treatment Review was suggested but not implemented before Sammy’s death. The court heard that such interventions may not have been successful but, in any event, North East London Foundation Trust had not been commissioned to provide anything other than a diagnostic service to children presenting with autism and learning disabilities rather than an overt mental health diagnosis.
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Diagnostic-only commissioning for children with autism and learning disabilities without an overt mental health diagnosis
Wider context from the report “(3) There was evidence given that the mental health team at North East London Foundation Trust were also aware of Sammy’s high-risk behaviours. Support had been provided by a psychology student in the past and he had reportedly responded well to mindfulness therapy and the de-escalation techniques employed by his family. Psychosocial interventions were not offered by the Mental Health Trust and a Care Education and Treatment Review was suggested but not implemented before Sammy’s death. The court heard that such interventions may not have been successful but, in any event, North East London Foundation Trust had not been commissioned to provide anything other than a diagnostic service to children presenting with autism and learning disabilities rather than an overt mental health diagnosis .
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge among service staff about available support
Wider context from the report “(2) Evidence was given at the inquest that the social workers from Kent County Council were fully aware of Sammy’s high-risk behaviour and had on several occasions referred him to their Children with Disabilities team who refused to assess him. Sammy’s behaviour was also having an adverse impact on his three younger siblings. His mother had repeatedly reported that she could not keep Sammy safe without support and had sought assistance from state agencies, Charites and done as much as she possibly could herself. Social workers took steps to try to access support for his family to enable them to care for him but the way services were managed meant those involved had little knowledge of what was available . One social worker gave evidence that Sammy’s behaviour had escalated between August 2019 and January 2020 when he did not have access to support in the home. However, despite being aware that Sammy needed more support to provide wrap around care before and after the school day only very limited support was funded from the end of January 2020. When the advice was given for him to shield in March 2020, due to the Covid 19 pandemic, he now had to isolate and was without the supportive school environment yet no replacement support was provided despite the need being obvious.
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient funding and replacement support for wrap-around home care
Wider context from the report “(2) Evidence was given at the inquest that the social workers from Kent County Council were fully aware of Sammy’s high-risk behaviour and had on several occasions referred him to their Children with Disabilities team who refused to assess him. Sammy’s behaviour was also having an adverse impact on his three younger siblings. His mother had repeatedly reported that she could not keep Sammy safe without support and had sought assistance from state agencies, Charites and done as much as she possibly could herself. Social workers took steps to try to access support for his family to enable them to care for him but the way services were managed meant those involved had little knowledge of what was available. One social worker gave evidence that Sammy’s behaviour had escalated between August 2019 and January 2020 when he did not have access to support in the home. However, despite being aware that Sammy needed more support to provide wrap around care before and after the school day only very limited support was funded from the end of January 2020 . When the advice was given for him to shield in March 2020, due to the Covid 19 pandemic, he now had to isolate and was without the supportive school environment yet no replacement support was provided despite the need being obvious .
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to implement suggested Care Education and Treatment Reviews
Wider context from the report “(3) There was evidence given that the mental health team at North East London Foundation Trust were also aware of Sammy’s high-risk behaviours. Support had been provided by a psychology student in the past and he had reportedly responded well to mindfulness therapy and the de-escalation techniques employed by his family. Psychosocial interventions were not offered by the Mental Health Trust and a Care Education and Treatment Review was suggested but not implemented before Sammy’s death . The court heard that such interventions may not have been successful but, in any event, North East London Foundation Trust had not been commissioned to provide anything other than a diagnostic service to children presenting with autism and learning disabilities rather than an overt mental health diagnosis.
” Open source report
13 Jan 2017 Natalie Gray · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 6 Failure to finalise discharge planning pathways for patients with personality disorder View source Ambiguous terminology in required mental health risk assessments View source Failure to record significant third-party information in Rio notes View source Failure to communicate and obtain doctor sign-off for risk ratings recorded by nurses or junior doctors View source Unclear escalation procedures for people at medium risk of self harm View source Failure to define whether risk assessments record present, chronic and historic risk View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Natalie Gray · 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
Natalie Gray died after leaving Priority House, where she was an informal patient, and jumping in front of a train at Barming railway station on 21 April 2015. The principal concerns included insufficient risk assessments, inadequate handovers and failures in procedures for informal patient leave, communication of risk, recording third-party information and reporting her absence to police.
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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise discharge planning pathways for patients with personality disorder
Wider context from the report “(1) The approach to discharge planning has been addressed on a general basis but the pathway for those with a diagnosis of personality disorder is currently under review and has not been finalised . It remains a concern that a patient with an emotionally unstable personality disorder will meet the current criteria for discharge but shortly thereafter be at risk particularly where specialist therapies are planned but have not been approved/started
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Ambiguous terminology in required mental health risk assessments
Wider context from the report “(3) Kent Police and Kent & Medway NHS & Social Care Partnership Trust have agreed a Missing Person Procedure implemented 1st December 2015. There is a concern about the terminology for use in the risk assessment that the Mental Health Trust is required to complete which may lead to an inaccurate risk assessments. There appears to be no explanation as to whether the risk is that formally documented, or the risk at the time the patient left the facility which may be less clear. Additionally the use of the term 'significant' is highly subjective , is it intended to mean a likely risk of self harm or something more. It is not clear how the Trust should deal with those likely to place themselves in danger and therefore at medium risk of self harm, in terms of the timescales involved and whether 999 should be used or not. By way of example, Natalie's documented risk was inaccurately recorded as low, when it should have been medium and on leaving the facility medium to high, this could lead to an underestimation of the risk of self harm depending on how the form is interpreted by staff .
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to record significant third-party information in Rio notes
Wider context from the report “(4) Significant information from third parties was not recorded in the Rio notes when received or at all
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and obtain doctor sign-off for risk ratings recorded by nurses or junior doctors
Wider context from the report “(2) The risk assessment form has not yet been addressed and is under review, there remains an issue as to whether the risk is recorded as a present risk alone or includes chronic risk (particularly for those with personality disorders) as oppose to historic risk. Although risk is discussed at handovers and ward rounds there is no evidence that the risk rating is communicated or signed off by the doctor when the record is completed by a nurse/junior 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unclear escalation procedures for people at medium risk of self harm
Wider context from the report “(3) Kent Police and Kent & Medway NHS & Social Care Partnership Trust have agreed a Missing Person Procedure implemented 1st December 2015. There is a concern about the terminology for use in the risk assessment that the Mental Health Trust is required to complete which may lead to an inaccurate risk assessments. There appears to be no explanation as to whether the risk is that formally documented, or the risk at the time the patient left the facility which may be less clear. Additionally the use of the term 'significant' is highly subjective, is it intended to mean a likely risk of self harm or something more. It is not clear how the Trust should deal with those likely to place themselves in danger and therefore at medium risk of self harm, in terms of the timescales involved and whether 999 should be used or not. By way of example, Natalie's documented risk was inaccurately recorded as low, when it should have been medium and on leaving the facility medium to high, this could lead to an underestimation of the risk of self harm depending on how the form is interpreted by staff.
” 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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to define whether risk assessments record present, chronic and historic risk
Wider context from the report “(2) The risk assessment form has not yet been addressed and is under review, there remains an issue as to whether the risk is recorded as a present risk alone or includes chronic risk (particularly for those with personality disorders) as oppose to historic risk . Although risk is discussed at handovers and ward rounds there is no evidence that the risk rating is communicated or signed off by the doctor when the record is completed by a nurse/junior doctor
” Open source report
Concerns raised 1 Inadequate long-term liaison psychiatry nurse staffing levels covering hospital emergency departments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lorna Frances Cullen · 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
Lorna Frances Cullen died after falling from the upper level of a multi-storey car park on 23 December 2012, following attendance at an emergency department where she left before receiving a mental health assessment. The principal concern was the long-term adequacy of liaison psychiatry nurse staffing in hospital emergency departments, as patients requiring assessment were regularly waiting well beyond the standard two-hour period.
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 NHS Kent and Medway Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate long-term liaison psychiatry nurse staffing levels covering hospital emergency departments
Wider context from the report “It became apparent that if the deceased had waited at the hospital she would not in fact have been seen until at least midnight and possibly later (more than twice the standard time). The reason for this was due to the fact that there was only one nurse on duty during the ‘late’ shift and in view of the fact that a mental health assessment takes between 2-3 hours the demand (the nurse on duty receives referrals from a number of different departments within the hospital) far exceeded the available staffing provision . It was apparent from the evidence of at least three witnesses that at the time of this death in 2012, patients in need of mental health assessment by the on-duty liaison psychiatry nurse were regularly waiting well in excess of 2 hours . The importance of a mental health assessment taking place as soon as possible after such a need has been identified is obvious. A specially trained psychiatry nurse is more likely to pick up on the more subtle indicators as to risk, that means it is more likely that appropriate management of that risk can be put into place thus affording the most effective preventative measures against self-harm and harm to others.
During the course of the inquest I heard evidence that as a result of review additional resources had been awarded to facilitate increased staffing levels and to provide a 24 hour service (previously there were no liaison nurses on duty after midnight ) thus providing continuation of services before and after midnight. I was advised that the additional levels of funding remain in place until at least the end of September 2014. The effect of these resources has been to significantly decrease the number of patients who require mental health assessments and who have to wait in excess of 2 hours. It has meant that staff can properly research a patient’s history prior to or as part of the assessment which is not only essential so far as assessing the individual patient but is useful in assessing priority as between patients waiting to be seen.
The matter of concern therefore relates to the long term (ie post September 2014) liaison psychiatry nurse staffing levels covering hospital emergency departments.
” Open source report
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Addressed to NHS Kent and Medway Clinical Commissioning Group, now represented here by NHS Kent and Medway Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations