Sarah Heaver
1 Sept 2025 · Coroner Sarah Clarke · Kent and Medway
The coroner's concerns
1. lack of neurological investigation
“appropriate neurological investigation was not carried out”
2. absence of structured neurological observations
“no structured neurological observations were undertaken on a patient presenting with such a low GCS”
3. incomplete medical records
“inconsistent, unreliable and incomplete medical records”
4. lack of psychiatric input after discharge
“patients are discharged from acute hospital settings on the understanding that they will receive psychiatric input equivalent to hospital admission, only for it to later become apparent that there is no access to a psychiatrist or prescriber for several days”
Responses
2026-0010-Response-from-East-Kent-Hospitals-University-NHS-Foundation-Trust.pdf ↗· East Kent Hospitals University NHS Foundation Trust
Stated action · Summer 2026
“The Trust has made improvements and changes since the letter from August 2025, which we hope reassures you that we are always learning and trying to improve patient care.”
2026-0010-Response-from-Kent-and-Medway-Mental-Health-NHS-Trust.pdf ↗· Kent and Medway NHS and Social Care Partnership Trust