Recurance · prevention of future deaths reports
Pre-inquest brief
Inconsistent and incomplete medical records
The earlier warning
Jonathan Fry · 16 May 2016 · Kate Thomas, Mid Kent and Medway
“Medical records were inconsistent and / or incomplete leading to a lack of clarity as to reviews and care plan.”
judiciary.uk/prevention-of-future-death-reports/jonathan-fry
What was promised
Stated action 1 · response to Kathryn Millard (25 Apr 2022) · stated timescale: monthly
“The Trust has also taken action to ensure that Anti-Embolic Stocking (AES) are prescribed and applied when indicated by the medical team. Safety messages and local teaching have occurred to ensure that nurses escalate incidents where an appliance has been indicated, but not prescribed. Since the recipient of this letter, the team has again sent out safety message to all nursing staff as a reminder of the expected standard. Compliance with expected practice will be audited monthly, and monitored”
judiciary.uk/…/2022-0121-Response-from-Medway-NHS-Foundation-Tr…
Stated action 2 · response to Kathryn Millard (25 Apr 2022) · stated timescale: Nov-22
“Changing the set up of the clinical team on the ward will allow the hierarchical tree with Change the 'Ward based structure to team based.”
judiciary.uk/…/2022-0121-Response-from-Medway-NHS-Action-Plan.p…
What recurred
- 3 Feb 2021 · Christopher Smith · Sonia Hayes · Closely related · confidence 0.90 (high)
- 25 Apr 2022 · Kathryn Millard · Ian Brownhill
- 15 Nov 2022 · Sally-Ann Few · Catherine Wood · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Jonathan Fry · 16 May 2016
“Medical records were inconsistent and / or incomplete leading to a lack of clarity as to reviews and care plan.”
Later · Sally-Ann Few · 15 Nov 2022
“At the inquest it was clear that the standard of record keeping by the medical staff was poor”
What happened next
No web check of the stated actions has been published for this chain.