PFD report

Megan Ceris Williams · Prevention of Future Deaths report

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Issued 24 Jul 2024•Central and South 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
6

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
21

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 raised6

  1. Lack of clinical staff knowledge of the Acute Abdominal Pain Pathway
    Part of recurring concern: Unreliable paediatric abdominal-pain assessment and escalation pathways
  2. Lack of a clearly documented and recorded process for patient self-discharge
    Part of recurring concern: Unreliable hospital discharge processes
  3. Failure to maintain a signed record of patient self-discharge
    Part of recurring concern: Unreliable hospital discharge documentationPart 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.

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.12

  1. Action

    Use the national Patient Safety Incident Investigation report template and include patient and family involvement in learning response reports.

    Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 September 2024.
  2. Action

    Add the Acute Abdominal Pain Pathway to the My ED App for clinician access.

    Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 September 2024.
  3. Action

    Adopt NHS guidance on engaging and involving patients, families and staff after patient safety incidents.

    Stated by East Kent Hospitals University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    The current training regime is considered sufficient to ensure staff understand the emergency management process for adult abdominal pain.

    Stated by East Kent Hospitals University NHS Foundation 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

Lack of clinical staff knowledge of the Acute Abdominal Pain Pathway

Wider context from the report

“Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery. It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction. The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022. The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene. The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged. The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning. The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family. (a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP). (b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians. (c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise. (d) There was not a clearly documented and recorded process for patients who self-discharge from hospital. ”

Is this part of a recurring concern?

Yes — Unreliable paediatric abdominal-pain assessment and escalation pathways.

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 clearly documented and recorded process for patient self-discharge

Wider context from the report

“Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery. It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction. The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022. The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene. The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged. The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning. The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family. (a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP). (b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians. (c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise. (d) There was not a clearly documented and recorded process for patients who self-discharge from hospital. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

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 maintain a signed record of patient self-discharge

Wider context from the report

“Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery. It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction. The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022. The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene. The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged. The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning. The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family. (a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP). (b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians. (c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise. (d) There was not a clearly documented and recorded process for patients who self-discharge from hospital. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge documentation; Unreliable hospital discharge processes.

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 the hospital SI process to include information from family and other interested persons

Wider context from the report

“Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery. It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction. The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022. The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene. The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged. The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning. The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family. (a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP). (b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians. (c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise. (d) There was not a clearly documented and recorded process for patients who self-discharge from hospital. ”

Is this part of a recurring concern?

Yes — Unreliable formal safety-incident management processes.

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 vomiting before hospital discharge

Wider context from the report

“Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery. It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction. The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022. The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene. The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged. The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning. The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family. (a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP). (b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians. (c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise. (d) There was not a clearly documented and recorded process for patients who self-discharge from hospital. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 the Acute Abdominal Pain Pathway documentation to provide sufficient clarity

Wider context from the report

“Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery. It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction. The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022. The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene. The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged. The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning. The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family. (a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP). (b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians. (c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise. (d) There was not a clearly documented and recorded process for patients who self-discharge from hospital. ”

Is this part of a recurring concern?

Yes — Unreliable paediatric abdominal-pain assessment and escalation pathways.

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

Use the national Patient Safety Incident Investigation report template and include patient and family involvement in learning response reports.

Verbatim wording from the response

“The Patient Safety Incident Response Framework and our Trust plan requires the use of a Patient Safety Incident Investigation (PSII) methodology for certain incident types. The Trust has adopted the national template for PSII reports (Document 6). This includes recording of the patient and family involvement in the investigation process. The other learning response reports that the Trust will be using e.g. After Action Review, Swarm, also prompt the inclusion of the patient and family perspective.”

Source location

Response from East Kent Hospitals
Page 3 · response
Published 30 September 2024

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

Add the Acute Abdominal Pain Pathway to the My ED App for clinician access.

Verbatim wording from the response

“In addition, the Trust’s Updated Action Plan implemented a procedure whereby a copy of the AAPP needs to be fully completed when a patient is admitted to the Emergency Department with complaints of abdominal pain. This process was implemented on 07 September 2022. Furthermore, as of 13 September 2022, the AAPP has now been added to the My ED App, this is to ensure it is readily and easily accessible to clinical staff assessing patients with complaints of abdominal pain.”

Source location

Response from East Kent Hospitals
Page 2 · response
Published 30 September 2024

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

Adopt NHS guidance on engaging and involving patients, families and staff after patient safety incidents.

Verbatim wording from the response

“In addition to the Policy and Plan, the Trust is adopting the NHS Engaging and involving patients, families and staff following a patient safety incident. The Trust’s Incident Management Policy has been updated (pending ratification) to ensure that patient and family involvement is strengthened. Similarly, the Trust’s Duty of Candour Policy (Document 5) will be reviewed and updated. For”

Source location

Response from East Kent Hospitals
Page 2 · response
Published 30 September 2024

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

Establish a Peer Review Panel to review learning response reports.

Verbatim wording from the response

“The Trust is implementing the Learning response review and improvement tool to enable peer review of reports. This includes the descriptor, “People affected by incidents are meaningfully engaged and involved”. This tool will be used by learning response leads and the Peer Review Panel described within the Trust Policy (section 12).”

Source location

Response from East Kent Hospitals
Page 3 · response
Published 30 September 2024

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

Update the Incident Management Policy to strengthen patient and family involvement, subject to ratification.

Verbatim wording from the response

“In addition to the Policy and Plan, the Trust is adopting the NHS Engaging and involving patients, families and staff following a patient safety incident. The Trust’s Incident Management Policy has been updated (pending ratification) to ensure that patient and family involvement is strengthened. Similarly, the Trust’s Duty of Candour Policy (Document 5) will be reviewed and updated. For”

Source location

Response from East Kent Hospitals
Page 2 · response
Published 30 September 2024

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 completion of the Acute Abdominal Pain Pathway for Emergency Department admissions involving abdominal pain.

Verbatim wording from the response

“In addition, the Trust’s Updated Action Plan implemented a procedure whereby a copy of the AAPP needs to be fully completed when a patient is admitted to the Emergency Department with complaints of abdominal pain. This process was implemented on 07 September 2022. Furthermore, as of 13 September 2022, the AAPP has now been added to the My ED App, this is to ensure it is readily and easily accessible to clinical staff assessing patients with complaints of abdominal pain.”

Source location

Response from East Kent Hospitals
Page 2 · response
Published 30 September 2024

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 post-discharge welfare telephone calls for ward patients who self-discharge.

Verbatim wording from the response

“Of key importance is that patients are asked to review the Self Discharge Form which must then be filed within the patient’s case notes. The Self Discharge Form sets out the risks of discharging against medical advice and asks a patient to consider these risks before signing the form. This is to ensure that patients have weighed the risks of self-discharge and ensures that there is a recorded process. The Policy also mandates that following discharge, if on a ward, then a welfare check telephone call be made to ensure the patient has arrived home safely.”

Source location

Response from East Kent Hospitals
Page 4 · response
Published 30 September 2024

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

Update and disseminate policies clarifying staff duties for missing patients and patients attempting self-discharge, including patient risk assessment.

Verbatim wording from the response

“To ensure a repeat of similar incidents does not re-occur, the Trust has also updated its policy relating to patients who self-discharge from hospital. Enclosed with this letter is the Trust’s updated Missing Persons Policy (Document 7) and the Discharge Criteria policy (Document 8). This has been through 3 separate reviews and updates since May 2022 and ensures that the duties of staff members relating to missing patients and patients who are attempting to self-discharge are clearly established. It also now includes an updated Patient Risk Assessment so that staff members can”

Source location

Response from East Kent Hospitals
Page 3 · response
Published 30 September 2024

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 Learning Response Review and Improvement Tool for peer review of reports.

Verbatim wording from the response

“The Trust is implementing the Learning response review and improvement tool to enable peer review of reports. This includes the descriptor, “People affected by incidents are meaningfully engaged and involved”. This tool will be used by learning response leads and the Peer Review Panel described within the Trust Policy (section 12).”

Source location

Response from East Kent Hospitals
Page 3 · response
Published 30 September 2024

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

Continue joint Emergency Medicine and Surgical teaching sessions reinforcing the Acute Abdominal Pain Pathway.

Verbatim wording from the response

“The reinforcement of the AAPP is a continuing process and has been happening throughout the last two years within the Trust. The Trust have a monthly joined Emergency Medicine and Surgical teaching session. This is a platform for these Departments to present and discuss cases they face in order to improve patient safety continuously. It is important to note that cases surrounding acute abdomen are frequent and therefore often require discussion of the AAPP. The AAPP is a feature of these discussions each time a relevant case is discussed.”

Source location

Response from East Kent Hospitals
Page 1 · response
Published 30 September 2024

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

Issue updated discharge guidance requiring capacity, safeguarding, consultation, medication, notification, documentation and self-discharge form checks.

Verbatim wording from the response

“In addition, the Trust has updated the Hospital Discharge and Criteria to Reside Policy. The Policy was updated and issued to all staff at the Trust on 16 February 2023. The updated policy directs staff to always consider the following when a patient indicates that they want to self-discharge:”

Source location

Response from East Kent Hospitals
Page 4 · response
Published 30 September 2024

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

Transition incident management to the Patient Safety Incident Response Framework, including patient and family involvement.

Verbatim wording from the response

“Since the conclusion of the inquest, the Trust has changed the SI process to the new Patient Safety Incident Response Framework. The Trust Patient Safety Incident Response Policy (Document 2) and Plan (Document 3) have been agreed and are attached for information.”

Source location

Response from East Kent Hospitals
Page 2 · response
Published 30 September 2024

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 current training regime is considered sufficient to ensure staff understand the emergency management process for adult abdominal pain.

Verbatim wording from the response

“The reinforcement of the AAPP is a continuing process and has been happening throughout the last two years within the Trust. The Trust have a monthly joined Emergency Medicine and Surgical teaching session. This is a platform for these Departments to present and discuss cases they face in order to improve patient safety continuously. It is important to note that cases surrounding acute abdomen are frequent and therefore often require discussion of the AAPP. The AAPP is a feature of these discussions each time a relevant case is discussed.”

Source location

Response from East Kent Hospitals
Page 1 · response
Published 30 September 2024

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

No actions by NICE are considered necessary to address the issues raised in the report.

Verbatim wording from the response

“On this occasion, we do not consider that there are any actions from NICE that would address the issues raised.”

Source location

Response from NICE
Page 1 · response
Published 30 September 2024

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

East Kent Hospitals University NHS Foundation Trust should respond to and address the concerns.

Verbatim wording from the response

“I note that you have also addressed your Report to East Kent Hospitals University NHS Foundation Trust (EKHT), and it is appropriate that they respond to each of the concerns raised by the Coroner, as these concerns do not fall under NHS England’s remit and are all local issues for the Trust to address.”

Source location

Response from NHS England
Page 1 · response
Published 30 September 2024

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 concerns are local Trust issues outside NHS England’s remit.

Verbatim wording from the response

“I note that you have also addressed your Report to East Kent Hospitals University NHS Foundation Trust (EKHT), and it is appropriate that they respond to each of the concerns raised by the Coroner, as these concerns do not fall under NHS England’s remit and are all local issues for the Trust to address.”

Source location

Response from NHS England
Page 1 · response
Published 30 September 2024

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.9

  1. 1

    Review and update the Duty of Candour Policy.

    Stated by East Kent Hospitals University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 September 2024.
  2. 2

    Consider how assurance of adherence to patient safety incident response standards will be sourced and reported.

    Stated by East Kent Hospitals University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 September 2024.
  3. 3

    Replace the Serious Incident Approval Panel with a Learning Response Approval Panel for approving Patient Safety Incident Investigations.

    Stated by East Kent Hospitals University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 September 2024.
  4. 4

    Review every same-complaint Emergency Department reattendance within 48 hours through the discharging team, document the review, and determine admission or discharge.

    Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 September 2024.
  5. 5

    Engage with NHS Kent and Medway Integrated Care Board about the concerns raised.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2024.
  6. 6

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 30 September 2024.
  7. 7

    Obtain and review the Trust’s response to determine whether further action is required.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 30 September 2024.
  8. 8

    Share learning and insights from Prevention of Future Deaths reports across the NHS nationally and regionally.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 30 September 2024.
  9. 9

    Monitor emerging trends from Prevention of Future Deaths reports for potential review and action.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2024.

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 and update the Duty of Candour Policy.

Verbatim wording from the response

“In addition to the Policy and Plan, the Trust is adopting the NHS Engaging and involving patients, families and staff following a patient safety incident. The Trust’s Incident Management Policy has been updated (pending ratification) to ensure that patient and family involvement is strengthened. Similarly, the Trust’s Duty of Candour Policy (Document 5) will be reviewed and updated. For”

Source location

Response from East Kent Hospitals
Page 2 · response
Published 30 September 2024

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

Consider how assurance of adherence to patient safety incident response standards will be sourced and reported.

Verbatim wording from the response

“In summary, the Trust has commenced implementation of Patient Safety Incident Framework and strengthened the processes to ensure the engagement of the patient, family and other stakeholders with the oversight of the Incident Review Panel. The planned implementation of the Peer Review Panel and the Learning Response Approval Panel will further strengthen the oversight of the inclusion of information from the patient, family and other stakeholders. In addition, the Trust also plans to consider how assurance of adherence to the patient safety incident response standards will be sourced and reported.”

Source location

Response from East Kent Hospitals
Page 3 · response
Published 30 September 2024

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

Replace the Serious Incident Approval Panel with a Learning Response Approval Panel for approving Patient Safety Incident Investigations.

Verbatim wording from the response

“The Trust will be replacing the previous Serious Incident Approval Panel with the Learning Response Approval Panel to approve Patient Safety Incident Investigations. The Care Group Triumvirates will be responsible for oversight and approval of some learning responses. In both instances the Trust will adopt the questions to guide local oversight of patient safety incident responses.”

Source location

Response from East Kent Hospitals
Page 3 · response
Published 30 September 2024

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

Review every same-complaint Emergency Department reattendance within 48 hours through the discharging team, document the review, and determine admission or discharge.

Verbatim wording from the response

“As per the Updated Action Plan, the Trust have implemented a new process whereby all patients who re-attend the Emergency Department within 48 hours of discharge for the same complaint are seen by the discharging team, this review is documented, and forms part of the patients records. This additional process is to ensure that the patient was not discharged when further investigation and/or treatment was required. The discharging team will review the patient on re-attendance, ensure no additional investigations are required and either admit or discharge accordingly.”

Source location

Response from East Kent Hospitals
Page 3 · response
Published 30 September 2024

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

Engage with NHS Kent and Medway Integrated Care Board about the concerns raised.

Verbatim wording from the response

“However, my regional colleagues in the South East are engaging with NHS Kent and Medway Integrated Care Board on the concerns raised, and NHS England has asked to be sighted on the Trust’s response to you. We will consider their response to the Coroner once received and whether any further actions are required. We would be happy to update the Coroner further if this is the case.”

Source location

Response from NHS England
Page 1 · response
Published 30 September 2024

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

Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Megan, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 1 · response
Published 30 September 2024

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

Obtain and review the Trust’s response to determine whether further action is required.

Verbatim wording from the response

“However, my regional colleagues in the South East are engaging with NHS Kent and Medway Integrated Care Board on the concerns raised, and NHS England has asked to be sighted on the Trust’s response to you. We will consider their response to the Coroner once received and whether any further actions are required. We would be happy to update the Coroner further if this is the case.”

Source location

Response from NHS England
Page 1 · response
Published 30 September 2024

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

Share learning and insights from Prevention of Future Deaths reports across the NHS nationally and regionally.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Megan, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 1 · response
Published 30 September 2024

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

Monitor emerging trends from Prevention of Future Deaths reports for potential review and action.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Megan, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 1 · response
Published 30 September 2024

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