Katherine Hogan

11th January 2021 

BY EMAIL ONLY 

HMC Ms Sonia Hayes 
Coroners Court 
Kent and Medway Coroner’s Service 
Cantium House 
Sandling Road 
Maidstone 
ME14 1XD 

Dear Madam 

Re: Katherine Mabel Hogan 
Conclusion of Inquest: 17th July 2020 

Chief Executive  
Maidstone and Tunbridge Wells NHS Trust 
Maidstone Hospital 
Hermitage Lane 
Maidstone 
Kent, ME16 9QQ 

Tel: 

Email: 

I  write  further  to  the  above  matter  and  the  Regulation  28  Report  received  by  the  Trust  dated  18th 
November 2020 issued under the Coroners (Investigations) Regulations 2013. I hope that this reply will 
be helpful in detailing the consideration given and actions taken to address the matters of concern in 
your report.  

First  and  foremost,  I  have  written  separately  to  the  family  of  Mrs  Hogan  to  offer  my  sincere 
condolences.   

As the Court will be aware, the Trust carried out an internal investigation as regards the circumstances 
leading  to  the  fall  sustained  by  Mrs  Hogan  on  16th  August  2019.    This  internal  investigation  was 
provided  to  the  Court  and  the  interested  persons.    As  part  of  the  Trust’s  continued  objective  to  learn 
and improve, this internal review was recently re-opened with the investigation scope further extended 
to cover the overall care afforded to Mrs Hogan, as opposed to focusing on the incident of the fall itself. 

In response to the issued Regulation 28 Report, I now respond in turn to the matters of concern raised: 

Concern 1)  
Staff shortages contributed to the patient being left the clinical decisions area of the unit on a 
trolley. This was not an area that was suitable to keep a patient overnight. Staff shortages were 
reported to those responsible for the hospital. 

Trust Response: 
Staffing  levels  at  the  time  of  the  incident  ought  to  have  comprised  7  registered  nurses  and  1  clinical 
support worker (CSW).  Actual staffing levels at the time of the incident were 5 registered nurses and 1 
CSW. There were  staffing  shortages of  1  registered nurse  from  the  start  of  this  shift  and  at  4am  this 
increased to staffing shortages of 2 registered nurses between the hours of 4am – 7.30am. 

The Trust regrets this shortage of staff; this staff deficit was due to one shift not being covered, and a 
member  of  the  nursing  team  commencing  their  shift  at  an  earlier  time  of  4pm  as  requested  by  the 

Chairman: 

            Chief Executive: 

Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ 
Telephone: 01622 729000   Fax: 01622 226416 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 nurse  in  charge  (This  led  to  the  nurse  finishing  her  shift  at  4am  rather  than  7am,  prior  to  the  index 
event). 

The  Court  was  provided  with  evidence  as  to  the  activity  levels  in the  A&E  department  on the  date of 
Mrs Hogan’s fall.  In the 24 hour period starting 15th August 00:01am to 16th August 00:00am the unit 
was  particularly  busy  with  222  attendances  to  the  department,  minimal  movement  of  patients,  with 
many  awaiting  transfer  to  beds  that  were  not  yet  available.    Whilst  we  do  not  seek  to  detract  from 
concerns raised, we hope this information assists as regards context.  

In  light  of  these  facts,  and  the  concern  noted  within  your  Report,  the  Trust  has  comprehensively 
considered  this  matter  further.    Going  forward  staff  have  been  reminded  that  if  staffing  levels  are 
identified  as  a  concern  this  should  be  escalated  by  the  senior  nursing  team  and  site  practitioner  to 
arrange  cover.    Staffing  concerns  must  also  be  reported  on  the  Trust’s  incident  reporting  system 
(DATIX) – so that these levels may be monitored and kept under review.  

As standard practice, staffing concerns are escalated at each daily site meeting.  The Nurse in charge 
has  the  responsibility  to  discuss  /  escalate  staffing  deficits  and  plans  to  a  Matron.      This  ‘horizon 
planning’ aids early identification of staffing shortages so that temporary / agency staff may be sourced 
as  required.    Nursing  staff  have  also  been  reminded  that  their  twice  daily  safety  huddles  in  each 
ward/department should be used to consider all concerns, including any staffing issues.  We have also 
introduced twice daily trust-wide safe staffing meetings, chaired by the Chief Nurse and attended by the 
Divisional Directors of Nursing and Quality. These meetings are used to understand risks anywhere in 
the Trust in relation to staffing and identify actions required to mitigate these risks. 

The patient was left in the CDU on a trolley due to the historical department protocol not being followed. 
The patient did not meet the admission criteria for the CDU however was still admitted to this area. As a 
result of this incident, action has been taken to update the department protocol and admission criteria. 
The  updated  department  protocol  and admission  criteria  has  been  disseminated to  all  staff  within the 
department.  The  updated  department  protocol  now  states  that  the  unit  must  be  closed  if  there  is  no 
suitable staff allocated to the unit.  

Concern 2)  
Evidence  is  that  the  unit  has  moved  and  has  been  reconfigured,  however  there  remains  an 
outstanding request for increased staffing that has not been addressed by the Trust. 

As the Court have noted, the Clinical Decision Unit (CDU) has been reconfigured. In line with this, the 
Trust now confirms that a Standard Operating Process (SOP) as regards the CDU has been updated 
and amended.  This SOP sets out the intended use of the CDU.  The provisions of this SOP include: 

  Clarity as regards the purpose of the CDU, in that it is a short-stay clinical assessment area rather 

than an overnight ward 

  The  criterion  for  the  use  of  this  unit  in  respect  of  treatment,  investigations  and  required 

interventions prior to discharge 

  Patients who require admission should not be placed in CDU for any period.  If an inpatient bed is 

required they should be admitted under the appropriate speciality 

Chairman: 

            Chief Executive: 

Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ 
Telephone: 01622 729000   Fax: 01622 226416 

 
 
 
 
 
 
 
 
 
 
 
 
   Exclusion criteria as regards the use of the CDU area (includes patients that score on our national 

early warning system) 

  A clear plan documented in the A&E notes  with likely discharge within 4 hours as agreed by the 

named responsible Doctor and Nurse in Charge 

Safe staffing levels have been reassessed since the reconfiguration of the department and incorporated 
into  the  rotas.  These  levels  also  form  part  of  the  basis  of  safe  staffing  reporting  to  the  Chief  Nurse. 
Senior nursing support has been increased with the successful recruitment of 3 additional Emergency 
Medicine  Matrons. The senior  support  Matron  cover  has  meant  that there is  cover  7 days  a week  on 
site  to  support  the  staff  within  the  department.    There  is  an  active  ongoing  recruitment  campaign  for 
Emergency Department nurses with regular recruitment days taking place. 

Royal  College  of  Emergency  Medicine  and  Getting  It  Right  First  Time  recommendations  on  staffing 
levels for Emergency Departments were released in September and October 2020 and the organisation 
is now using these clear staffing recommendations to benchmark safe staffing levels for each shift. This 
has led to the creation of additional posts within the department which are being substantially recruited 
to. 

The organisation re-opened the serious incident investigation to review the care provided to Mrs Hogan 
and  have  created  a  revised  action  plan  to  address  all  issues  identified.  The  action  plan  is  being 
finalised with the senior nursing team within the Emergency Department. This should be completed by 
the  end  of  this  month,  at  which  point  the  re-opened  SI  investigation  report  and  action  plan  will  be 
shared with the family for review and input. 

As evidenced by the re-opening of the internal review of this regrettable event, we aim to continue to 
learn wherever possible from concerns raised with the Trust so as to improve the services we offer to 
all our patients. 

Yours sincerely 

Chief Executive 

Chairman: 

            Chief Executive: 

Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ 
Telephone: 01622 729000   Fax: 01622 226416