“During the course of the hearing it became apparent that the Trust do not have an…”

The coroner’s concerns

During the course of the hearing it became apparent that the Trust do not have an electronic record keeping system. The evidence indicated that electronic notes enhance the ability of clinicians to document and provide care and aid communication between different clinical teams and departments. Here this impacted on the care provided to the deceased as a referral to the haematology team needed to be printed out and placed in a tray in the secretaries office and the haematology registrar on call had to check the tray intermittently (usually morning, lunchtime and at the end of the afternoon). The referral took over 34 hours to be acted upon and it was likely that the reliance on paper based notes led to delays in the referral being acted upon and appropriate advice and management provided. There were also issues in being able to access records held by other organisations as the staff at Darent Valley hospital did not have access to any previous clinical notes from other organisations to confirm his diagnosis. Staff had to ring the Trust where the deceased had been previously seen for his Sickle cell disease and ask them to forward relevant information. This led to a lack of clarity in the notes regarding Mr. Mukaila's sickle cell status. It was not clear whether he was on a Sickle Cell Registry and had undergone annual reviews. Had there been accessible notes between different NHS organisations his medical history would have been clear and may have assisted with clinical decision making which in turn may have had an impact on his care and treatment. Access to electronic notes at the earliest opportunity would make it far easier for clinical staff to provide appropriate care and treatment. Whilst I found at the hearing that these issues did not more than minimally or trivially contribute to the death it would undoubtedly lead to a risk of future deaths for others. 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. His family 2.Dartford and Gravesham NHS Trust I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026) Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. Signature RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 When a coroner sends a prevention of future deaths (PFD) report to a person or organisation, they must respond within 56 days. Recipients of a PFD report can apply to the coroner for an extension. A response to a PFD report must detail the action taken or to be taken, whether in response to the report or otherwise, or it must explain why no action is proposed. The purpose of the response template below is to promote clarity, ensure that responses address the coroner’s concerns directly and transparently, and support consistency and good practice across organisations and sectors. It does not restrict how a person or organisation formulates their response; recipients remain responsible for determining what action is appropriate and for ensuring that their response accurately reflects the steps taken or planned.

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, 2026-0376

Added to Minute Book

7 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0