“Ann’s malnutrition and declining frailty were not investigated despite continued requests…”
Dated 7 Jun 2025, from the coroner for North East Kent. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 2 Aug 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated7 Jun 2025
- Deadline2 Aug 2025
- Published on judiciary.uk15 Jul 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East Kent Hospitals University NHS Foundation TrustNamed in the report as “East Kent University Hospitals Foundation Trust” | Response publishedPublished on judiciary.uk in July 2025. |
| The Manor Clinic Folkestone Kent | Response publishedPublished on judiciary.uk in July 2025. |
The coroner’s concerns
1. Ann’s malnutrition and declining frailty were not investigated despite continued requests by Ann and her family to primary and secondary care settings. 2. Ann’s marked Anemia and poor nutritional state meant that she was not suitable for potentially lifesaving treatment when it became necessary. 3. No internal investigations were conducted by Ann’s GP or by the East Kent Hospitals NHS Foundation Trust to establish if lessons could be learned as a result of the circumstances of Ann’s Death. 4. The Court was informed that there had been an SJR (of which I had not previously been notified) following Ann’s death. The Dr providing evidence was to raise a Datix in relation to Ann’s previous attendances and failed discharges. At the resumed inquest the Court were informed these investigations had not taken place and were not to take place. 5. No consideration was given prior to Ann’s final admission and some 18 months after the onset of symptoms of vomiting and chronic weightless, of support for Ann’s nutritional status. 6. If Ann had been in a better nutritional state on her final admission to the Kent and Canterbury, then she would have been well enough to undergo lifesaving treatment following the bladder perforation. 6. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths, and I believe that your organisation has the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 4th August 2025. I, the Coroner, may extend this period if necessary.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0335
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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