Mark Vidler
1 Dec 2025 · Coroner Ian Potter · Kent and Medway
The coroner's concerns
1. staff focus on process
“Some staff at the Trust were so focussed on 'process' that they lost sight of the need for patient centred care.”
2. lack of clarity in referral triaging
“The process in place for triaging and considering referrals to the Rapid Response Team is reliant, for the most part, on call handlers working through a script and there is a total lack of clarity regarding clinical decision making in this regard.”
3. masking of symptoms not acknowledged
“Evidence I considered showed that some risk factors, such as the masking of symptoms, were well documented. However, the HTT clinician still appeared not to acknowledge the extent of such risks.”
4. pre-determined discharge decision
“the decision to discharge [the deceased] from the HTT was made at a multi- disciplinary team (MDT) meeting prior to the HTT nurse visiting [the deceased] on 6 May 2025. This”
5. MHT+ team excluded from MDT decision
“Both the nurse from MHT+ and the consultant psychiatrist gave evidence that the MHT+ were not included, as the receiving team, in the MDT decision on 6 May 2025.”
6. absence of care co-ordinators
“I heard evidence that the Trust does not have care co-ordinators and the clinician felt that this could lead to similar situations arising in the future.”