“A Rapid Access Treatment Protocol (RATT) was not in operation as a result of a busy A&E…”
Dated 17 Feb 2016, from the coroner for Mid Kent and Medway. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 13 Apr 2016. A reply may have been sent and not yet published.
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.
- Report dated17 Feb 2016
- Deadline13 Apr 2016
- Published on judiciary.uk17 Feb 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Maidstone and Tunbridge Wells NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 13 Apr 2016. A reply may have been sent and not yet published. |
The coroner’s concerns
– (1) A Rapid Access Treatment Protocol (RATT) was not in operation as a result of a busy A&E department which was short staffed. This resulted in a delay in triage (2) The patient was not seen by a doctor for 2 hours 20 minutes despite being PAR 5 and requiring therefore an immediate review by a senior doctor (3) There was a delay in ownership and onward management of the patient which resulted in timely decisions not being made. On call consultants responsible for those decisions were not aware of the patient deteriorating because they did not personally review the patient and were not informed of, or did not secure updated information themselves of how acutely unwell the patient was. (4) Despite a vascular site declining to accept the patient until his renal function was optimised and a CT angiogram performed, a delay was caused by enquiries being made whether a second vascular site would accept the patient (5) The ITU of the hospital to which the patient was transferred were not informed of the transfer
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, 2016-0063
- 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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