“Sarah Heaver was admitted with a GCS of 3, later improving to between 5–8/15, with…”
Dated 1 Sep 2025, from the coroner for Kent and Medway. 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 publishedOrganisations 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 dated1 Sep 2025
- Deadline27 Oct 2025
- Published on judiciary.uk20 Jan 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Kent and Medway NHS and Social Care Partnership Trust | Response publishedPublished on judiciary.uk in January 2026. |
| East Kent Hospitals University NHS Foundation Trust | Response publishedPublished on judiciary.uk in January 2026. |
The coroner’s concerns
(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. (2) I am concerned that no structured neurological observations were undertaken on a patient presenting with such a low GCS, risking deterioration being missed. (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. (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.
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, 2026-0010
- Added to Minute Book
- 8 Oct 2026
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- 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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