“There was confusion in the terminology used between nursing staff or doctors and the…”
Dated 19 May 2014, 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
All responses publishedReplies were due by 14 Jul 2014.
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 dated19 May 2014
- Deadline14 Jul 2014
- Published on judiciary.uk19 May 2014
- 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 May 2014. |
| Maidstone and Tunbridge Wells NHS Trust | Response publishedPublished on judiciary.uk in May 2014. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
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) There was confusion in the terminology used between nursing staff or doctors and the CRISIS team when out of hours calls were made such that it was not clear between parties whether a referral, advice or assessment was sought (2) Relevant information/advice was not provided by the CRIS!S team to parties who had made referrals (3) Mr. Franklin’s GP would have initiated a multidisciplinary team meeting to address the increasing frequency of attendances at hospital had he been aware of the recent hospital admission, the subsequent involvement with the mental health team and the attendances et A&E. The documentation from both hospital and mental health trusts was subject of significant delays such that none of the letters to the GP sent by either trust from July onward arrived with the GP before Mr. Franklin died
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, 2014-0230
- 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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