PFD report

Sarah Heaver · Prevention of Future Deaths report

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Issued 9 Jan 2026•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
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
11

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 raised4

  1. Failure to undertake structured neurological observations
    Part of recurring concern: Failure to carry out required neurological observations
  2. Failure to undertake appropriate neurological investigation
  3. Unavailability of psychiatric input after acute hospital discharge
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.9

  1. Action

    Develop and submit a revised digital deteriorating-patient pathway for testing, including automatic GCS access and mandatory completion where indicated.

    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 20 January 2026.
  2. Action

    Present documentation standards and accurate-recording expectations during junior doctor Trust induction.

    Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
  3. Action

    Present revised neurological assessment and escalation standards at Urgent, Emergency, and Acute Medicine governance meetings.

    Stated by East Kent Hospitals University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 January 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    No CT scan was warranted because there were no trauma signs, neurological indicators, or other clinical features requiring imaging after naloxone response.

    Stated by East Kent Hospitals University 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

Failure to undertake structured neurological observations

Wider context from the report

“(2) I am concerned that no structured neurological observations were undertaken on a patient presenting with such a low GCS, risking deterioration being missed. ”

Is this part of a recurring concern?

Yes — Failure to carry out required neurological observations.

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 undertake appropriate neurological investigation

Wider context from the report

“(1) Sarah Heaver was admitted with a GCS of 3, later improving to between 5–8/15, with unknown downtime and an unclear history. A CT head scan was indicated and not undertaken. I am concerned that appropriate neurological investigation was not carried out. ”

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

Unavailability of psychiatric input after acute hospital discharge

Wider context from the report

“(4) I am concerned that patients are discharged from acute hospital settings on the understanding that they will receive psychiatric input equivalent to hospital admission, only for it to later become apparent that there is no access to a psychiatrist or prescriber for several days, particularly over bank holiday periods. ”

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

Inconsistent, unreliable and incomplete medical records

Wider context from the report

“(3) Throughout this investigation I was presented with inconsistent, unreliable and incomplete medical records. This significantly hindered my ability to investigate the death and creates a risk of future patient harm. ”

Is this part of a recurring concern?

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

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 and submit a revised digital deteriorating-patient pathway for testing, including automatic GCS access and mandatory completion where indicated.

Verbatim wording from the response

“parameter is entered (i.e. any response other than “Alert”), the system prompts the user to indicate whether a Glasgow Coma Scale (GCS) assessment is required. However, even when a clinician confirms that a GCS assessment is clinically indicated, completion of the GCS remains non-mandatory, and observations may be submitted without this assessment being recorded. Furthermore, the current configuration requires the clinician to manually locate and complete the GCS assessment further down within the flowsheet, which introduces risk of omission during time-critical situations.”

Source location

Response from East Kent Hospitals University NHS Foundation Trust
Page 3 · response
Published 20 January 2026

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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

Present documentation standards and accurate-recording expectations during junior doctor Trust induction.

Verbatim wording from the response

“As an aside, this case was discussed in the Trust’s Mortality meeting and the general consensus was that management was appropriate in accordance with NICE guidance. The inquest did highlight issues with documentation, it was not of an optimal standard and not in line with GMC Good Medical Practice guidance. We have presented this to the Junior Doctors on their trust induction as well to ensure that notes are accurately recorded and not ‘copy and pasted’.”

Source location

Response from East Kent Hospitals University NHS Foundation Trust
Page 2 · response
Published 20 January 2026

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

Present revised neurological assessment and escalation standards at Urgent, Emergency, and Acute Medicine governance meetings.

Verbatim wording from the response

“• Governance Meetings The revised policy will be formally presented at Urgent, Emergency, and Acute Medicine governance meetings by the Consultant team. This ensures that clinical expectations and gold-standard practice in the assessment, escalation, and management of patients with reduced or fluctuating GCS are clearly communicated and understood across relevant specialties.”

Source location

Response from East Kent Hospitals University NHS Foundation Trust
Page 4 · response
Published 20 January 2026

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 Vital Signs Policy to require escalation for neurological deterioration and fifteen-minute then thirty-minute observations during Naloxone infusions.

Verbatim wording from the response

“In addition, as mentioned in the Trust’s letter in August 2025, the Vital Signs Policy has been reviewed and updated effective from November 2025. This revision incorporates specific learning identified from the incident involving Mrs Heaver and reflects the Trust’s commitment to continuous improvement, education, and the embedding of best practice into clinical governance frameworks.”

Source location

Response from East Kent Hospitals University NHS Foundation Trust
Page 3 · response
Published 20 January 2026

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 improvements to electronic documentation of neurological observations.

Verbatim wording from the response

“The Trust’s letter in August 2025 showed how Mrs Heaver’s GCS improved rapidly during transport (after the bolus of Naloxone) and then upon admission to hospital. However, review of the notes identified the need for improved documentation of neurological observations. The case identified the need for standardised and frequent GCS documentation. The Trust’s Deteriorating Patient Lead Nurse has reviewed the notes and implemented improvements to the Trust’s electronic documentation system.”

Source location

Response from East Kent Hospitals University NHS Foundation Trust
Page 2 · response
Published 20 January 2026

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

Embed revised neurological deterioration and escalation standards within ALERT and accredited Immediate Life Support training programmes.

Verbatim wording from the response

“Importantly, this policy update is not solely procedural amendments but are actively embedded within the Trust’s education and training infrastructure. The revised standards now inform and support the following programmes:”

Source location

Response from East Kent Hospitals University NHS Foundation Trust
Page 4 · response
Published 20 January 2026

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 prescribing cross-cover through a three-prescriber rolling rota for weekends, bank holidays, annual leave and sickness.

Verbatim wording from the response

“At the time of the inquest of Mrs Heaver, the Trust had already identified that there was a lack of consistent cover provided for prescribing over weekends. This was identified by the Service Manager in February 2025, when it became apparent that all 3 Independent prescribers were on annual leave at the same time. This had unfortunately occurred due to 2 of the 3 undertaking additional training at university and they had not been able to utilise their leave in line with Trust policy. As a trust we will ensure this situation does not arise again. At the time of identifying this shortfall in regards to appropriate prescribing cover, in consultation with the three independent prescribers and ████████, Consultant Psychiatrist, it was agreed that there would be a change in working pattern for the three independent prescribers subsequently working on a three-week rolling rota.”

Source location

Response from Kent and Medway Mental Health NHS Trust
Page 2 · response
Published 20 January 2026

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

Transfer responsibility for booking and agreeing prescribers’ annual leave to Operational Team Managers.

Verbatim wording from the response

“The responsibility for appropriate booking and agreement of annual leave was also transferred from the medical staff and was added to the rostering responsibility of the Operational Team Managers. This has now become established practice. All 3 prescribers now provide cross cover for both teams on all weekends, bank holidays, annual leave or sickness and this is reviewed in the teams total staffing cover weekly by the Operational Team managers. It has been agreed that if required, NHS Professionals can be utilised to provide prescribing cover, if the need should arise.”

Source location

Response from Kent and Medway Mental Health NHS Trust
Page 2 · response
Published 20 January 2026

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 total prescribing staffing cover weekly through the Operational Team Managers.

Verbatim wording from the response

“The responsibility for appropriate booking and agreement of annual leave was also transferred from the medical staff and was added to the rostering responsibility of the Operational Team Managers. This has now become established practice. All 3 prescribers now provide cross cover for both teams on all weekends, bank holidays, annual leave or sickness and this is reviewed in the teams total staffing cover weekly by the Operational Team managers. It has been agreed that if required, NHS Professionals can be utilised to provide prescribing cover, if the need should arise.”

Source location

Response from Kent and Medway Mental Health NHS Trust
Page 2 · response
Published 20 January 2026

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 CT scan was warranted because there were no trauma signs, neurological indicators, or other clinical features requiring imaging after naloxone response.

Verbatim wording from the response

“████████, in preparation for this response has confirmed that his stance would remain the same. The evidence and handover from the paramedics on arrival was clear on the history of Mrs Heaver. Whilst the timing of the overdose was unclear, she had no signs of trauma i.e. a head injury which would have necessitated a CT. It was evident that she had taken an overdose and the medication blisters packs were found next to her.”

Source location

Response from East Kent Hospitals University NHS Foundation Trust
Page 1 · response
Published 20 January 2026

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

KPMT is responsible for providing the full response concerning access to psychiatric input or prescribing after acute hospital discharge.

Verbatim wording from the response

“We believe that this was an issue that arose at the inquest itself and KPMT will respond to this in full.”

Source location

Response from East Kent Hospitals University NHS Foundation Trust
Page 4 · response
Published 20 January 2026

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.2

  1. 1

    Continue highlighting the case and its learning in Trust learning activities.

    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 20 January 2026.
  2. 2

    Establish inquest-record communication procedures through Standard Operating Procedures, performance indicators, and designated case handlers.

    Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.

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 highlighting the case and its learning in Trust learning activities.

Verbatim wording from the response

“We hope that the changes and learning that has taken place reassure the coroner that we have taken steps to mitigate this sad case repeating itself and the Trust will continue to highlight this case in learning situations.”

Source location

Response from East Kent Hospitals University NHS Foundation Trust
Page 5 · response
Published 20 January 2026

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 inquest-record communication procedures through Standard Operating Procedures, performance indicators, and designated case handlers.

Verbatim wording from the response

“The coroner will be aware that the legal services department in the Trust was under immense pressure last year when this inquest was opened and concluded. There was high staff turnover and the department was not running effectively. A review of the file notes that numerous requests were made by the coroner’s officers for the medical records and imaging but this was unfortunately not sent in a timely manner. This caused the inquest to be adjourned and caused distress to the family. The Trust apologises for this. The team is evolving and undergoing a period of transformation to ensure that communication happens promptly. We have put in stringent Standard Operating Procedures (SOP’s), Key Performance Indicators (KPI’s) and introduced case handlers for each inquest to ensure that, from the offset, key information is provided to the coroner and the officers.”

Source location

Response from East Kent Hospitals University NHS Foundation Trust
Page 4 · response
Published 20 January 2026

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