PFD report

KATHERINE MABEL HOGAN · Prevention of Future Deaths report

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Issued 18 Nov 2020•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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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 raised2

  1. Failure to keep patients in a suitable area overnight
    Part of recurring concern: Failure to provide suitable accommodation for patients awaiting care
  2. Lack of adequate staffing in the unit
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.7

  1. Action

    Escalate staffing concerns through senior nursing and site-practitioner channels, record them on DATIX, and monitor them through staffing reviews.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 24 December 2020.
  2. Action

    Continue recruiting Emergency Department nurses and substantially recruit newly created additional department posts.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 December 2020.
  3. Action

    Update the CDU standard operating process to define its short-stay purpose, admission and exclusion criteria, discharge planning, and prohibition on placing patients requiring admission there.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 24 December 2020.

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 keep patients in a suitable area overnight

Wider context from the report

“(1) Staff shortages contributed to the patient being left the clinical decisions area of the unit on a trolley. This was not an area that was suitable to keep a patient overnight. Staff shortages were reported to those responsible for the hospital. (2) Evidence is that the unit has moved and has been reconfigured, however there remains an outstanding request for increased staffing that has not been addressed by the Trust. ”

Is this part of a recurring concern?

Yes — Failure to provide suitable accommodation for patients awaiting 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

Lack of adequate staffing in the unit

Wider context from the report

“(1) Staff shortages contributed to the patient being left the clinical decisions area of the unit on a trolley. This was not an area that was suitable to keep a patient overnight. Staff shortages were reported to those responsible for the hospital. (2) Evidence is that the unit has moved and has been reconfigured, however there remains an outstanding request for increased staffing that has not been addressed by the Trust. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Escalate staffing concerns through senior nursing and site-practitioner channels, record them on DATIX, and monitor them through staffing reviews.

Verbatim wording from the response

“In light of these facts, and the concern noted within your Report, the Trust has comprehensively considered this matter further. Going forward staff have been reminded that if staffing levels are identified as a concern this should be escalated by the senior nursing team and site practitioner to arrange cover. Staffing concerns must also be reported on the Trust’s incident reporting system (DATIX) – so that these levels may be monitored and kept under review.”

Source location

2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
Page 2 · response
Published 24 December 2020

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 recruiting Emergency Department nurses and substantially recruit newly created additional department posts.

Verbatim wording from the response

“Safe staffing levels have been reassessed since the reconfiguration of the department and incorporated into the rotas. These levels also form part of the basis of safe staffing reporting to the Chief Nurse. Senior nursing support has been increased with the successful recruitment of 3 additional Emergency Medicine Matrons. The senior support Matron cover has meant that there is cover 7 days a week on site to support the staff within the department. There is an active ongoing recruitment campaign for Emergency Department nurses with regular recruitment days taking place.”

Source location

2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
Page 3 · response
Published 24 December 2020

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 CDU standard operating process to define its short-stay purpose, admission and exclusion criteria, discharge planning, and prohibition on placing patients requiring admission there.

Verbatim wording from the response

“As the Court have noted, the Clinical Decision Unit (CDU) has been reconfigured. In line with this, the Trust now confirms that a Standard Operating Process (SOP) as regards the CDU has been updated and amended. This SOP sets out the intended use of the CDU. The provisions of this SOP include:”

Source location

2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
Page 2 · response
Published 24 December 2020

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

Provide increased senior nursing support by recruiting three Emergency Medicine Matrons and establishing seven-day on-site cover.

Verbatim wording from the response

“Safe staffing levels have been reassessed since the reconfiguration of the department and incorporated into the rotas. These levels also form part of the basis of safe staffing reporting to the Chief Nurse. Senior nursing support has been increased with the successful recruitment of 3 additional Emergency Medicine Matrons. The senior support Matron cover has meant that there is cover 7 days a week on site to support the staff within the department. There is an active ongoing recruitment campaign for Emergency Department nurses with regular recruitment days taking place.”

Source location

2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
Page 3 · response
Published 24 December 2020

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

Introduce twice-daily Trust-wide safe-staffing meetings to identify staffing risks and required mitigating actions.

Verbatim wording from the response

“As standard practice, staffing concerns are escalated at each daily site meeting. The Nurse in charge has the responsibility to discuss / escalate staffing deficits and plans to a Matron. This ‘horizon planning’ aids early identification of staffing shortages so that temporary / agency staff may be sourced as required. Nursing staff have also been reminded that their twice daily safety huddles in each ward/department should be used to consider all concerns, including any staffing issues. We have also introduced twice daily trust-wide safe staffing meetings, chaired by the Chief Nurse and attended by the Divisional Directors of Nursing and Quality. These meetings are used to understand risks anywhere in the Trust in relation to staffing and identify actions required to mitigate these risks.”

Source location

2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
Page 2 · response
Published 24 December 2020

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 the department protocol and admission criteria, including closure of the unit when suitable staffing is unavailable.

Verbatim wording from the response

“The patient was left in the CDU on a trolley due to the historical department protocol not being followed. The patient did not meet the admission criteria for the CDU however was still admitted to this area. As a result of this incident, action has been taken to update the department protocol and admission criteria. The updated department protocol and admission criteria has been disseminated to all staff within the department. The updated department protocol now states that the unit must be closed if there is no suitable staff allocated to the unit.”

Source location

2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
Page 2 · response
Published 24 December 2020

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

Reassess safe staffing levels, incorporate them into rotas, and use national recommendations to benchmark staffing and inform safe-staffing reporting.

Verbatim wording from the response

“Safe staffing levels have been reassessed since the reconfiguration of the department and incorporated into the rotas. These levels also form part of the basis of safe staffing reporting to the Chief Nurse. Senior nursing support has been increased with the successful recruitment of 3 additional Emergency Medicine Matrons. The senior support Matron cover has meant that there is cover 7 days a week on site to support the staff within the department. There is an active ongoing recruitment campaign for Emergency Department nurses with regular recruitment days taking place.”

Source location

2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
Page 3 · response
Published 24 December 2020

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

    Finalize the revised action plan arising from the reopened serious-incident investigation and share the investigation report and plan with the family for input.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 December 2020.

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

Finalize the revised action plan arising from the reopened serious-incident investigation and share the investigation report and plan with the family for input.

Verbatim wording from the response

“The organisation re-opened the serious incident investigation to review the care provided to Mrs Hogan and have created a revised action plan to address all issues identified. The action plan is being finalised with the senior nursing team within the Emergency Department. This should be completed by the end of this month, at which point the re-opened SI investigation report and action plan will be shared with the family for review and input.”

Source location

2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
Page 3 · response
Published 24 December 2020

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