PFD report

Winifred Olive DENNIS · Prevention of Future Deaths report

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Issued 14 Apr 2014•North East Kent

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised1

  1. Lack of formal handover and transfer of important information between community nursing teams
    Part of recurring concern: Unreliable handover of care information and responsibilityPart of recurring concern: Unreliable healthcare patient transfer 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.4

  1. Action

    Monitor transfer-of-care arrangements through clinical audit and Trust committee structures.

    Stated by Kent Community Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 April 2014.
  2. Action

    Improve transfer documentation so patients receive holistic reassessment and clearly documented care needs before transfer.

    Stated by Kent Community Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 April 2014.
  3. Action

    Revise transfer-of-care policies and procedures through an established working group.

    Stated by Kent Community Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 April 2014.

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 handover and transfer of important information between community nursing teams

Wider context from the report

“(1) The evidence was that within Kent Community Health NHS Trust the community nurses are organised into teams dependent upon the GP surgeries that they are covering. As a result, the moving of a patient from her own home to a Care Home, or between Care Homes, can cause her to be transferred from one Community Nursing Team to another, occurred in this instance. Although from the patient's notes would be transfer, the Trust had no formal handover document as such for a patient in these circumstances, and in this instance, the information that at her previous Home she had had the benefit of an airflow mattress was not communicated to the next Home on her move there. Care Homes look to the community nurses for such guidance. (2) In other cases, similar important information not directly of a clinical nature might not be transferred and the chances of optimum care being delivered to a patient might accordingly be reduced. ”

Is this part of a recurring concern?

Yes — Unreliable handover of care information and responsibility; Unreliable healthcare patient transfer processes.

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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

Monitor transfer-of-care arrangements through clinical audit and Trust committee structures.

Verbatim wording from the response

“Response A formal process to enable the transfer of care between community nursing teams has been devised. A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care. Work is already underway to improve the documentation associated with transfer to ensure all patients have a full holistic reassessment prior to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care. This process ensures continuity of care. Patients’ on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to staff for holistic assessment and care planning has been revised and the new programme is now being rolled out.”

Source location

2014-0167-Response-by-Kent-Community-Health-NHS-Trust
Page 1 · response
Published 14 April 2014

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Improve transfer documentation so patients receive holistic reassessment and clearly documented care needs before transfer.

Verbatim wording from the response

“Response A formal process to enable the transfer of care between community nursing teams has been devised. A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care. Work is already underway to improve the documentation associated with transfer to ensure all patients have a full holistic reassessment prior to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care. This process ensures continuity of care. Patients’ on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to staff for holistic assessment and care planning has been revised and the new programme is now being rolled out.”

Source location

2014-0167-Response-by-Kent-Community-Health-NHS-Trust
Page 1 · response
Published 14 April 2014

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Revise transfer-of-care policies and procedures through an established working group.

Verbatim wording from the response

“Response A formal process to enable the transfer of care between community nursing teams has been devised. A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care. Work is already underway to improve the documentation associated with transfer to ensure all patients have a full holistic reassessment prior to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care. This process ensures continuity of care. Patients’ on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to staff for holistic assessment and care planning has been revised and the new programme is now being rolled out.”

Source location

2014-0167-Response-by-Kent-Community-Health-NHS-Trust
Page 1 · response
Published 14 April 2014

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Implement a formal process for transferring care between community nursing teams.

Verbatim wording from the response

“Response A formal process to enable the transfer of care between community nursing teams has been devised. A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care. Work is already underway to improve the documentation associated with transfer to ensure all patients have a full holistic reassessment prior to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care. This process ensures continuity of care. Patients’ on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to staff for holistic assessment and care planning has been revised and the new programme is now being rolled out.”

Source location

2014-0167-Response-by-Kent-Community-Health-NHS-Trust
Page 1 · response
Published 14 April 2014

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

    Roll out a revised staff training programme for holistic assessment and care planning.

    Stated by Kent Community Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 April 2014.

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

Roll out a revised staff training programme for holistic assessment and care planning.

Verbatim wording from the response

“Response A formal process to enable the transfer of care between community nursing teams has been devised. A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care. Work is already underway to improve the documentation associated with transfer to ensure all patients have a full holistic reassessment prior to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care. This process ensures continuity of care. Patients’ on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to staff for holistic assessment and care planning has been revised and the new programme is now being rolled out.”

Source location

2014-0167-Response-by-Kent-Community-Health-NHS-Trust
Page 1 · response
Published 14 April 2014

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