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recurance

Ernest Gray

7 Nov 2025 · Coroner Patricia Harding · Kent and Medway

The coroner's concerns

  1. 1. lack of contact with partner

    “Mr. [name redacted] next of kin was his daughter but he lived with his 86 year old partner. His daughter was consulted in the discharge process but the hospital did not attempt to contact his partner who was his carer.”
  2. 2. lack of holistic discharge planning

    “Although a number of persons from diƯerent disciplines were involved in planning Mr. [name redacted] discharge, there was no evidence of a holistic approach being taken of the discharge or in communication of the patient's ongoing needs following discharge”
  3. 3. lack of information about delirium risks

    “Mr. [name redacted] daughter was informed two days before the discharge that he had hyperactive delirium and that it would resolve itself but could take a few weeks. She was not made aware that Mr [name redacted] had at times been agitated and violent in hospital, nor was she told that although the hyperactive delirium was resolving it could fluctuate because it was likely triggered by a metabolic cause (renal function), heart failure or myocardial infarction. Neither she nor Mr. [name redacted] partner were informed as to how symptoms may manifest or what to do if Mr [name redacted] was symptomatic. Had they known that Mr [name redacted] may become aggressive or violent to others particularly his carers, an early discharge would not have been encouraged”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Ernest Gray · Recurance