PFD report

Johanna Marie MORELAND · Prevention of Future Deaths report

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Issued 11 Jul 2021•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
3

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. Delays in making lumbar puncture results available
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted uponPart of recurring concern: Failure to provide timely urgent diagnostic investigations
  2. Failure to carry out required observations following liver biopsy
    Part of recurring concern: Unreliable patient observation arrangements
  3. Failure to record required observation levels in medical records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable patient observation arrangements
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

    Develop a post-procedure handover form for use after every procedure.

    Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.
  2. Action

    Require written confirmation of post-procedure observation frequency and handover to nursing staff through the new process.

    Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2021.
  3. Action

    Reiterate the post-procedure observation policy to nursing staff through recurring Big 4 ward messaging.

    Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The viral lumbar puncture results were received within the normal turnaround time for this outsourced investigation.

    Stated by Medway NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Delays in making lumbar puncture results available

Wider context from the report

“(1) Results from lumbar puncture taken on 26th February 2021 were made available on 4th March 2021. Evidence heard at the inquest was that Lumbar Puncture tests are usually for diagnosis of serious illness and would usually be made available within 24-48 hours. (2) The Lumbar Puncture results were positive for encephalitis and in the absence of the tests results, a liver biopsy was conducted and, there was a delay in antiviral treatment commencing. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon; Failure to provide timely urgent diagnostic investigations.

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 to carry out required observations following liver biopsy

Wider context from the report

“(3) The Trust policy on the required levels of observations following a liver biopsy were not followed on return to the ward due to a miscommunication between Trust staff and the required levels of observations was not recorded in the medical records. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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 to record required observation levels in medical records

Wider context from the report

“(3) The Trust policy on the required levels of observations following a liver biopsy were not followed on return to the ward due to a miscommunication between Trust staff and the required levels of observations was not recorded in the medical records. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable patient observation arrangements.

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

Develop a post-procedure handover form for use after every procedure.

Verbatim wording from the response

“This report from the Coroner has identified an opportunity for improvement to process within the Trust, and to reduce the likelihood of any similar circumstance the Trust has developed the attached handover form to be competed post every procedure (Appendix 1). This process is led by the Consultant Radiologist and will include written confirmation of frequency of observations to be carried out, as well as written confirmation of handover to nursing staff. Trust policy for post procedure observations has been reiterated to all nursing staff subsequently through consistent inclusion in the Trust’s ‘Big 4’ ward based messaging.”

Source location

2021-0240-Response-from-Medway-Maritime-Hospital_Published
Page 3 · response
Published 15 July 2021

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 written confirmation of post-procedure observation frequency and handover to nursing staff through the new process.

Verbatim wording from the response

“This report from the Coroner has identified an opportunity for improvement to process within the Trust, and to reduce the likelihood of any similar circumstance the Trust has developed the attached handover form to be competed post every procedure (Appendix 1). This process is led by the Consultant Radiologist and will include written confirmation of frequency of observations to be carried out, as well as written confirmation of handover to nursing staff. Trust policy for post procedure observations has been reiterated to all nursing staff subsequently through consistent inclusion in the Trust’s ‘Big 4’ ward based messaging.”

Source location

2021-0240-Response-from-Medway-Maritime-Hospital_Published
Page 3 · response
Published 15 July 2021

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

Reiterate the post-procedure observation policy to nursing staff through recurring Big 4 ward messaging.

Verbatim wording from the response

“This report from the Coroner has identified an opportunity for improvement to process within the Trust, and to reduce the likelihood of any similar circumstance the Trust has developed the attached handover form to be competed post every procedure (Appendix 1). This process is led by the Consultant Radiologist and will include written confirmation of frequency of observations to be carried out, as well as written confirmation of handover to nursing staff. Trust policy for post procedure observations has been reiterated to all nursing staff subsequently through consistent inclusion in the Trust’s ‘Big 4’ ward based messaging.”

Source location

2021-0240-Response-from-Medway-Maritime-Hospital_Published
Page 3 · response
Published 15 July 2021

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 viral lumbar puncture results were received within the normal turnaround time for this outsourced investigation.

Verbatim wording from the response

“The Trust has investigated the timeframe for the availability of Mrs Moreland’s results. The cerebrospinal fluid (CSF) sample was taken on Friday 26th February 2021 and was received at the Pathology department at 17:28 on the same evening. The standard cell count, protein and glucose levels and bacterial screening and culture, performed in our microbiology laboratory at North Kent Pathology Services based at Dartford, was available within normal turnaround time of 24-48hrs and was unremarkable.”

Source location

2021-0240-Response-from-Medway-Maritime-Hospital_Published
Page 2 · response
Published 15 July 2021

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 positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The liver biopsy was undertaken independently of the lumbar puncture results and was not caused by any delay in receiving them.

    Stated by Medway NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 liver biopsy was undertaken independently of the lumbar puncture results and was not caused by any delay in receiving them.

Verbatim wording from the response

“(2) The Lumbar Puncture results were positive for encephalitis and in the absence of the tests results, a liver biopsy was conducted and, there was a delay in antiviral treatment commencing.”

Source location

2021-0240-Response-from-Medway-Maritime-Hospital_Published
Page 2 · response
Published 15 July 2021

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