PFD report

Ricky Anderson · Prevention of Future Deaths report

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Issued 9 Sep 2013•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.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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

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Concerns raised3

  1. Inadequate direct assessment of discharged patients' wellbeing and needs by the Access team
  2. Failure to inform the GP of hospital admissions involving primary care
    Part of recurring concern: Failure to reliably notify primary care of changes affecting patient carePart of recurring concern: Unreliable inter-agency information sharing for coordinated care
  3. Failure to put a care plan in place to establish needs before early discharge
    Part of recurring concern: Unreliable hospital discharge processes
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 direct assessment of discharged patients' wellbeing and needs by the Access team

Wider context from the report

“(2) Evidence at the Inquest that following Mr. Anderson's discharge from hospital a number of attempts were made to contact him to assess his wellbeing and needs. Although Mr. Anderson was spoken to briefly, it was accepted by the Trust that too much reliance was placed on information from family members. As a result Mr. Anderson had virtually no contact with the Access team prior to his death. I understand that a practice note has recently been drafted which is intended to be used as guidance ”

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

Failure to inform the GP of hospital admissions involving primary care

Wider context from the report

“(1) It was established in evidence at the inquest that practitioners from the Kent and Medway NHS and Social Care Partnership Trust did not inform Mr. Anderson's GP of his involvement with primary care on either occasion he was admitted to hospital, resulting in him not being able to obtain a further supply of medication without the intervention of his family ”

Is this part of a recurring concern?

Yes — Failure to reliably notify primary care of changes affecting patient care; Unreliable inter-agency information sharing for coordinated care.

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 put a care plan in place to establish needs before early discharge

Wider context from the report

“Mr. Anderson's discharge from hospital occurred at an earlier stage than had been planned as he wished to leave and was deemed safe to do so. As a consequence, a care plan had not been put in place to establish his needs. I heard evidence that following Mr. Anderson's death procedures have been put in place to ensure that this situation does not reoccur ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

Open source report
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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