“It was established in evidence at the inquest that practitioners from the Kent and Medway…”
Dated 9 Sep 2013, from the coroner for Mid 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 26 Jan 2014, after the 56 days for replies had ended (4 Nov 2013). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated9 Sep 2013
- Deadline4 Nov 2013
- Published on judiciary.uk26 Jan 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS Kent and Medway Integrated Care BoardNamed in the report as “Kent and Medway NHS” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 26 Jan 2014, after the 56 days for replies had ended (4 Nov 2013). These dates can’t tell us whether a reply was due before it went online. |
| Social Care Partnership Trust | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 26 Jan 2014, after the 56 days for replies had ended (4 Nov 2013). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) It was established in evidence at the inquest that practitioners from the Kent and Medway NHS and Social Care Partnership Trust did not inform Mr. Anderson’s GP of his involvement with primary care on either occasion he was admitted to hospital, resulting in him not being able to obtain a further supply of medication without the intervention of his family (2) Evidence was given at the Inquest that following Mr. Anderson’s discharge from hospital a number of attempts were made to contact him to assess his wellbeing and needs. Although Mr. Anderson was spoken to briefly, it was accepted by the Trust that too much reliance was placed on information from family members. As a result Mr. Anderson had virtually no contact with the Access team prior to his death. | understand that a practice note has recently been drafted which is intended to be used as guidance Mr. Anderson's discharge from hospital occurred at an earlier stage than had been planned as he wished to leave and was deemed safe to do so. As a consequence, a care plan had not been put in place to establish his needs. | heard evidence that following Mr. Anderson’s death procedures have been put in place to ensure that this situation does not reoccur
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, 2013-0227
- Added to Minute Book
- 8 Oct 2026
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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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