Report evidence summary
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of formal mental capacity assessments for treatment decisions
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of regular dietitian input for malnutrition
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” Is this part of a recurring concern? Yes — Inadequate management of malnutrition risk .
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of application of emollients for severe exfoliative dermatitis
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients . Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Requirement for severely ill inpatients to attend benefit offices in person
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim . I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Inadequate provision of food and fluid to meet patient needs
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure of multidisciplinary meetings to focus on treatment needs
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of specialist dermatology review for severe exfoliative dermatitis
Wider context from the report “Evidence was heard at the Inquest that Mr Talbot suffered an exceptionally rare life-threatening reaction to prescription medication for Bipolar Affective Disorder whilst he was detained under the Mental Health Act that included whole body severe exfoliative dermatitis. Mr Talbot was discharged from acute hospital to his psychiatric hospital several times within the first week of his diagnosis. He was readmitted to the acute hospital as his condition deteriorated. There was a lack of formal mental capacity assessments for his capacity to consent to and/or refuse treatment. There was an absence of regular dermatology review and lack of application of emollients. Food and fluid was not adequate to meet his needs leading to malnutrition and continued despite the insertion of a nasogastric tube in February.
(1) Chief Executive of Kent & Medway Social Care Partnership Trust on concerns relating to issuing test Terence Talbot had begun to exhibit symptoms of a depressive phase of his Bipolar Affective Disorder just prior to his discharge back to psychiatric hospital at the end of November 2019. Issues relating to capacity to make specific decisions in relation to Terence Talbot’s care and treatment were not all subjected to formal Mental Capacity Act assessments when he was refusing medical interventions that were in his best interests in the clinical picture of an extremely rare and complex medical diagnosis that arose due to his reaction to prescribed medication to treat his mental disorder and evidence of increasing low mood and symptoms consistent with depression.
(2) Chief Executive of Maidstone & Tunbridge Wells NHS Foundation Trust as to the lack of consideration of specialty dermatology referral with deteriorating severe exfoliative dermatitis in a rare and complex diagnosis. There was a lack of regular dietitian input with malnutrition. The evidence was the focus was on problems relating to discharge rather than treatment during multidisciplinary meetings. Issues relating to capacity to consent to, or refuse treatment were not all subjected to mental capacity assessments.
(3) Secretary of Work & Pensions to improve public health, welfare and safety due to a concern that circumstances creating a risk of further deaths may occur, or will continue to exist, in the future. The Department of Work & Pensions required Terence Talbot to attend in person to make a claim for benefits rather than accept an electronic claim. I heard from all the doctors and a senior nurse in this case who have a considerable experience across a range of specialties and across several different NHS Trusts that they have never experienced nor heard of a case where a severely ill inpatient was required by the Department of Work & Pensions to leave hospital to attend its offices in person to make a claim for welfare benefits. Terence Talbot was suffering with a mental disorder and an exceptionally rare and complex disease with a risk of death and suffering severe exfoliative dermatitis that rendered him very vulnerable to infection.
” Open source report
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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 Trigger alternative identity-verification processes when a claimant indicates they are in hospital.
Verbatim wording from the response “Where a claimant is unable to verify their ID online, they are no longer automatically directed to contact the UC helpline to book an appointment. Jobcentre agents are now responsible for booking all ID appointments. In the majority of cases, claimants will now be booked a biographical check by phone. Jobcentre agents have full access to the claimant’s account, including all answers provided by the claimant to the questions that form part of the application process. Jobcentre staff are trained to identify and provide support to customers with complex needs. If a claimant indicates that they are in hospital, this should trigger the Jobcentre agent to invoke alternative processes for verifying ID.” Source location 2021-0419-Response-from-DWP_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Give Jobcentre agents full claimant-account access and training to identify and support customers with complex needs.
Verbatim wording from the response “Where a claimant is unable to verify their ID online, they are no longer automatically directed to contact the UC helpline to book an appointment. Jobcentre agents are now responsible for booking all ID appointments. In the majority of cases, claimants will now be booked a biographical check by phone. Jobcentre agents have full access to the claimant’s account, including all answers provided by the claimant to the questions that form part of the application process. Jobcentre staff are trained to identify and provide support to customers with complex needs. If a claimant indicates that they are in hospital, this should trigger the Jobcentre agent to invoke alternative processes for verifying ID.” Source location 2021-0419-Response-from-DWP_Published
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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 Assign Jobcentre agents responsibility for booking identity appointments and usually conducting biographical identity checks by telephone.
Verbatim wording from the response “Where a claimant is unable to verify their ID online, they are no longer automatically directed to contact the UC helpline to book an appointment. Jobcentre agents are now responsible for booking all ID appointments. In the majority of cases, claimants will now be booked a biographical check by phone. Jobcentre agents have full access to the claimant’s account, including all answers provided by the claimant to the questions that form part of the application process. Jobcentre staff are trained to identify and provide support to customers with complex needs. If a claimant indicates that they are in hospital, this should trigger the Jobcentre agent to invoke alternative processes for verifying ID.” Source location 2021-0419-Response-from-DWP_Published
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 Implement strengthened remote identity verification using two-factor authentication and online checks against background sources.
Verbatim wording from the response “In November 2021 we changed our processes around ID verification. The revised process helps to strengthen the ID verification to reduce fraud and error. We have introduced two-factor authentication by SMS or email. The online identity check verifies the claimant’s identity by cross-referencing their personal information against a variety of background sources. As UC is a digital service, we are aiming to provide a remote option to verify ID where possible and safe to do so.” Source location 2021-0419-Response-from-DWP_Published
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 Progress a jointly owned KMPT–MTW initiative providing dedicated physical-health advice and streamlined admission routes for inpatients.
Verbatim wording from the response “1) A new initiative is being progressed, which will mitigate the risk of disjointed working with MTW, and will allow for seamless communication between our in-patient services and MTW. This initiative is being jointly developed and is jointly owned by KMPT and MTW and involves dedicated staff from MTW providing timely advice and guidance to our staff on physical health conditions and a streamlined route for admissions to an MTW bed when required.” Source location 2021-0419-Response-from-Kent-and-Medway-NHS-and-Social-Care-Partnership-Trust_Published
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a streamlined Mental Capacity Assessment process for physical-health interventions and monitor compliance through Mental Health Act Committee and CLiQ checks.
Verbatim wording from the response “2) A robust monitoring of Mental Capacity Assessment of patients under our care is conducted via Mental Health Act Committee (led by the Chief Medical Officer and reporting to Trust Board) thereby ensuring the highest level of scrutiny around this. Assurance on this is provided via a Clinical Quality check (CLiQ check) process across all our services particularly the in-patient services. Since September 2021 we have implemented a streamlined process for Mental capacity assessment which was developed using Quality Improvement methodology by our Quality Improvement team. This has resulted in significant improvement in completion and documentation of Mental Capacity Assessments and Best Interest decisions where capacity is lacking.” Source location 2021-0419-Response-from-Kent-and-Medway-NHS-and-Social-Care-Partnership-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver and monitor mandatory Mental Capacity Act training for clinical staff.
Verbatim wording from the response “3) The Mental Capacity Act (MCA) training for the organisation is closely monitored, again via the Mental Health Act Committee. MCA training is mandatory for all our clinical staff and we are currently at ninety percent completion rate for this training.” Source location 2021-0419-Response-from-Kent-and-Medway-NHS-and-Social-Care-Partnership-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a service-level agreement with MTW supporting patients detained under the Mental Health Act to receive physical-health treatment at MTW.
Verbatim wording from the response “4) KMPT has signed a Service level agreement with MTW to support patients detained under the Mental Health Act receiving treatment at MTW for their physical health needs. A training package is being delivered to MTW staff by the Mental Health Act compliance manager. This will significantly improve the understanding of the needs of patients with complex psychiatric conditions admitted to MTW.” Source location 2021-0419-Response-from-Kent-and-Medway-NHS-and-Social-Care-Partnership-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a Mental Capacity Act training package to MTW staff to improve understanding of patients with complex psychiatric conditions.
Verbatim wording from the response “4) KMPT has signed a Service level agreement with MTW to support patients detained under the Mental Health Act receiving treatment at MTW for their physical health needs. A training package is being delivered to MTW staff by the Mental Health Act compliance manager. This will significantly improve the understanding of the needs of patients with complex psychiatric conditions admitted to MTW.” Source location 2021-0419-Response-from-Kent-and-Medway-NHS-and-Social-Care-Partnership-Trust_Published
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 Nominate a lead clinician to review and clarify urgent and non-urgent dermatology referral pathways.
Verbatim wording from the response “With regards to referral pathways and specialty dermatology referrals, the Trust’s Clinical Director for specialist medical services has been asked to nominate a lead clinician to review the pathway into” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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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 Use Sunrise electronic records to record and monitor MUST findings.
Verbatim wording from the response “▪ An electronic patient records system (Sunrise) was introduced in Summer 2020 within the electronic recording of MUST, this system allows for better monitoring of the findings of the MUST;” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide mandatory tailored capacity-assessment training and conduct Trust-wide audit and monitoring.
Verbatim wording from the response “Along with the above training, the Trust continues to provide tailored, bespoke training sessions to all staff regarding the vital importance of capacity assessments. Again, regular audit and monitoring is being applied Trust wide. Such training is mandatory for each clinical member of staff.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete and weekly repeat MUST nutrition screening for all patients to identify deterioration and dietetic intervention needs.
Verbatim wording from the response “▪ All patients continue to have a Malnutrition Universal Screening Tool (MUST) score completed on admission and weekly thereafter to detect any deterioration and ensure dietetic intervention;” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Feed dermatology learning back to services and use the case as an educational tool.
Verbatim wording from the response “The dermatology issues identified in this case have been fed back to the dermatology services. In turn, the learning from this case is being used as an educational tool.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue joint Trust meetings and develop safety-netting arrangements for patients receiving dual care.
Verbatim wording from the response “Response
The Trust has explored the improvement of treatment pathways of inpatient care when patients are under dual care of KMPT and MTW. A meeting has taken place between both Trusts to discuss safety” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recommence ward-based nursing training delivered by the Dietetics Department.
Verbatim wording from the response “▪ Ward training of nursing staff by the Dietetics Department was suspended during 2020 due to Covid pressures however, the Trust is now recommencing these training sessions;” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Scope whether to include or contract external dermatology services within the current pathway.
Verbatim wording from the response “dermatology services for critical diseases, to ensure there is clarity regarding urgent and non-urgent cases. It is expected that the identified clinician will take up this role in by the end of this month. Scoping the option of including/contracting East Kent Hospitals University Foundation Trusts Dermatology Services into our current pathway will form part of this clinicians’ commission. Once this has been completed additional training will be commissioned by the Trust to increase the awareness to our staff regarding the services & pathways which are available. The objective of this training will be to ensure that there is Trust wide awareness of available support systems in relation to dermatology.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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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 Provide monthly dietitian teaching to Clinical Support Workers on MUST, escalation and available support.
Verbatim wording from the response “▪ Dietitians have been attending Clinical Support Worker (CSW) training days monthly to teach MUST, escalation and outline support available;” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit ward-based therapy assistants to support eating, drinking and speech and language therapy.
Verbatim wording from the response “▪ Ward-based therapy assistants are being recruited. Their focus will also include assisting patients with eating and drinking and speech and language therapy.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen monitoring of inpatient food charts through multidisciplinary discussions with the neighbouring mental health Trust.
Verbatim wording from the response “In order to ensure comprehensive learning from this matter, and as part of the MDT discussions with our neighbouring mental health Trust, the Trust is committed to ensuring further vigilance with regards to the monitoring of food charts for inpatients with physical and mental health needs.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue auditing MUST completion to assess practice changes and further training needs.
Verbatim wording from the response “▪ Audits of MUST completion continue to be undertaken. The next one is scheduled to be carried out in March 2022 to ascertain changes to practice and any further training required.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide seven-day Matron cover to support staff with referrals and escalation.
Verbatim wording from the response “To further support staff the Trust has Matron cover in place seven days a week, which ensures senior support and presence on site. This role supports staff within departments and includes assistance with referrals and escalation as required.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a clinical advisor role and appoint a Mental Capacity Act clinical practitioner to support complex capacity cases.
Verbatim wording from the response “Further, the Trust has introduced a new clinical advisor role as the lead clinician on capacity. The Trust has also appointed a new Mental Capacity Act clinical practitioner who will be available to assist the wards in dealing with complex cases. These leads will strengthen our oversight in ensuring the appropriate considerations around capacity are comprehensively covered.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an initiative with KMPT to strengthen communication and clarify joint treatment pathways.
Verbatim wording from the response “▪ The Trust will work with KMPT on an initiative which will aim to strengthen communications and mitigate risks to patients who receive care from both organisations. This initiative will be developed and managed by both Trusts and will provide clarity regarding joint treatment pathways.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and complete an audit of consent and mental capacity practices.
Verbatim wording from the response “Response
The Court is respectfully advised that the Trust has commissioned an audit into its consent and capacity practices. The external Trust Auditor has found that the Trust is broadly performing well. The recommendations from this review have been discussed by the Directorate leads and taken forward as part of the DATIX action plan noted above.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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PFD Monitor interpretation Monitor implementation of the response actions and share lessons learned to improve services.
Verbatim wording from the response “Thank you for bringing your concerns to my attention. Whilst I do not seek to detract from the concerns raised, I hope the above detail provides assurance that the Trust has taken these concerns seriously and will continue to deliver the actions outlined in our response. In addition, the implementation of these actions will be monitored and any lessons learned will be shared in order to improve the services we offer to all our patients.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission additional staff training on available dermatology services, referral pathways and support systems.
Verbatim wording from the response “dermatology services for critical diseases, to ensure there is clarity regarding urgent and non-urgent cases. It is expected that the identified clinician will take up this role in by the end of this month. Scoping the option of including/contracting East Kent Hospitals University Foundation Trusts Dermatology Services into our current pathway will form part of this clinicians’ commission. Once this has been completed additional training will be commissioned by the Trust to increase the awareness to our staff regarding the services & pathways which are available. The objective of this training will be to ensure that there is Trust wide awareness of available support systems in relation to dermatology.” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing support, reasonable adjustments and November 2021 identity-verification changes are considered sufficient for vulnerable claimants to access benefits; no specific changes are proposed.
Verbatim wording from the response “We are constantly reviewing the service we provide to claimants across all DWP services and are committed to improving accessibility for all our customers, especially the many vulnerable people who rely our services. As highlighted in our response, once we were fully aware of Mr Talbot’s circumstances, we made reasonable adjustments based on his needs. This was to enable Mr Talbot to manage and maintain his UC claim. Upon reviewing the full circumstances of this case and in light of the changes made in November 2021, we are satisfied that the appropriate support is available to allow vulnerable claimants with complex needs to access benefits and, on that basis, we do not propose to take any specific actions or make any changes at this time in response to the concerns raised by HM Assistant Coroner.” Source location 2021-0419-Response-from-DWP_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Jobcentre attendance requirement was for identity verification, not the Habitual Residence Test, and alternatives were available if inability to attend was reported.
Verbatim wording from the response “As part of his online application, Mr Talbot disclosed that he had been out of the UK for more than 4 weeks at a time. This prompted a check to determine whether a HRT interview was needed. I understand, from the evidence adduced at inquest, that there was a suggestion that the reason Mr Talbot was asked to attend a DWP Jobcentre was due to HRT requirements. This is not the case. Claimants are notified of the need to have a HRT when first attending the Jobcentre for their IEI as part of the usual process of making a claim. Mr Talbot was required to attend in person to verify his ID as he had not completed this online via GOV.UK Verify. Had DWP been made aware of concerns about Mr Talbot’s ability to attend a DWP Jobcentre in person, a referral could have been completed for a home visit or support visit.” Source location 2021-0419-Response-from-DWP_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust does not itself provide dermatology services, limiting its direct responsibility for specialist dermatology referral.
Verbatim wording from the response “Response
Awareness and escalation techniques form part of training that is delivered to nursing colleagues. As identified within the hearing, the Trust, (albeit not in a timely manner), did obtain community dermatology opinion and support (the Court will recall that the Trust does not provide dermatology services itself).” Source location 2021-0419-Response-from-Maidstone-Hospital_Published
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