“The reasons for the failure to correctly diagnose and treat Timothy on the 16% March 2018…”
Dated 26 Oct 2018, from the coroner for North West Kent. 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 23 Apr 2019, after the 56 days for replies had ended (21 Dec 2018). 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 dated26 Oct 2018
- Deadline21 Dec 2018
- Published on judiciary.uk23 Apr 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Maidstone and Tunbridge Wells NHS TrustNamed in the report as “Maidstone & Tunbridge Wells NHS Trust” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 23 Apr 2019, after the 56 days for replies had ended (21 Dec 2018). These dates can’t tell us whether a reply was due before it went online. |
| NHS England | Response publishedPublished on judiciary.uk in April 2019. |
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) The reasons for the failure to correctly diagnose and treat Timothy on the 16% March 2018 at 03.30. What staff instructions were given to the doctors and nurses in the Emergency Department at the hospital for dealing with patients with symptoms suggestive of sepsis and what tests should have been carried out and why they were not done. (2) Why was Timothy discharged home on the morning of the 16 March 2018 when he was clearly very unwell and tests had not been carried out. (3) What steps have been taken by the Trust to avoid this situation happening again to another patient in the future. (4) What training is being given to the doctors and nurses to avoid this situation in the future. (5S) How it happened that Timothy did not receive the Men ACWY vaccination and what systems are in place to ensure patients do receive the vaccination, how this is provided and monitored by NHS England and whether this is adequate or Should be improved to avoid patients failing to receive the vaccine. (
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, 2018-0351
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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