PFD report

Christine McNamara · Prevention of Future Deaths report

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Issued 16 Nov 2015•Mid Kent and Medway

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Unavailability of a surgical consultant on call from Maidstone during the working week
    Part of recurring concern: Unreliable consultant attendance when clinically required
  2. Lack of a pathway or guideline for post-ERCP patients who develop complications
    Part of recurring concern: Failure to recognise and manage post-endoscopy complications
  3. Restriction of out-of-hours radiography referrals to consultant-to-consultant referral
    Part of recurring concern: Unreliable Consultant-to-Consultant referral processes
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

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

    Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 November 2015.
  2. Action

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

    Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 November 2015.
  3. Action

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

    Stated by Maidstone and Tunbridge Wells NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 16 November 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

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

    Stated by Maidstone and Tunbridge Wells NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

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

Wider context from the report

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

Is this part of a recurring concern?

Yes — Unreliable consultant attendance when clinically required.

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

Wider context from the report

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

Is this part of a recurring concern?

Yes — Failure to recognise and manage post-endoscopy complications.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

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

Wider context from the report

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

Is this part of a recurring concern?

Yes — Unreliable Consultant-to-Consultant referral processes.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

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

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

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

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

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

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

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

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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

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

Verbatim wording from the response

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

Source location

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

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

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

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Provide CT scans out of hours when clinically necessary.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 16 November 2015.

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 CT scans out of hours when clinically necessary.

Verbatim wording from the response

“As ████████ explained at the inquest hearing, although CT scans are helpful in diagnosing patients they are by no means the only diagnostic tool, and where possible alternatives (which do not expose patients to potentially harmful levels of radiation) should always be considered. Where necessary, based on clinical presentation, we will always provide a CT scan for a patient who requires one - including out of hours.”

Source location

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

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026