Sarah Heaver

HM Coroner Sarah Clarke  
North East Kent Coroners 
Oakwood House  
Oakwood Road  
Maidstone  
Kent 
ME16 8AE 

Chief Executives Office 
Trust Offices 
Kent & Canterbury Hospital 
Ethelbert Road 
Canterbury 
Kent 
CT1 3NG 

  6th March 2026   

Dear Ma’am 

Regulation 28- Prevention of Future Deaths (PFD) response on behalf of East Kent 
Hospitals University NHS Foundation Trust regarding the death of Mrs Sarah Heaver.  

This is a formal response to the PFD issued to East Kent Hospitals University NHS Foundation 
Trust (the “Trust”). At the conclusion of the inquest on 23rd July 2025, the coroner afforded the 
opportunity  for  the  Trust  to  respond  to  her  concerns  before  issuing  a  PFD  (a  copy  of  this 
response is attached for ease). This response was sent on the 3rd August 2025.  

The coroner’s concerns within the PFD are the same as the concerns from the conclusion of 
the  inquest.  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. 

1.  Coroner’s concern: She had a GCS of 3 with unknown down time and an unclear 
history.  No  CT  was  undertaken  despite  being  indicated.  I  am  concerned  that 
appropriate neurological investigation was not carried out.  

In his evidence at the inquest and in the August 2025 letter, 
guidelines: 

 referenced the following 

1.  NICE CG176 (Head Injury guidelines) 
2.  Royal College of Emergency Medicine guidelines on self-harm 
3.  2022 NICE guidance (NG225) guidance on self-harm. 

,  in  preparation  for  this  response  has  confirmed  that  his  stance  would  remain  the 
same. The evidence and handover from the paramedics on arrival was clear on the history of 
Mrs Heaver. Whilst the timing of the overdose was unclear, she had no signs of trauma i.e. a 
head  injury  which  would  have  necessitated  a  CT.  It  was  evident  that  she  had  taken  an 
overdose and the medication blister packs were found next to her. 

After convening her to hospital and administering a bolus of Naloxone in the ambulance, her 
GCS improved significantly to 8 (from 3) by the time she was handed over to the resus team 
at A&E, her GCS further improved very rapidly to 13.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Mrs Heaver’s presentation is sadly not uncommon in A&E and there are clear guidelines on 
when a CT is mandated when a patient presents after self-harm. For self-harm involving head 
injury  or  potential  loss  of  consciousness,  standard  urgent  care  protocols  for  head  injury 
assessment should be followed, which is outlined in the NICE Head injury guidelines NG232 
(section 1.5, page 17,18).  

In NG232, self-harm is mentioned as an indication for CT Head, if the patient has a dangerous 
mechanism of injury or if the clinician is unable to obtain a reliable history due to the patient 
being intoxicated. 

Red flag signs for urgent CT Head in Head injury: 

1.  GCS <13 
2.  On anticoagulation 
3.  Trauma signs (panda eyes, battle's sign, CSF leak from nose / ear, suspected skull 

fracture 

4.  Two or more episodes of vomiting  
5.  Neurological deficit (limb weakness, speech problems) 

If Mrs Heaver had not responded to her Naloxone infusion, this could have indicated that there 
was something else happening clinically (i.e. a brain bleed) and a CT would have been carried 
out immediately upon arrival to A&E.  

Mrs Heaver recovered clinically from this attendance and there was nothing exhibited during 
that attendance that warranted a CT scan being undertaken. There was nothing to suggest 
that her mental health related to a tumour and indeed this was an incidental finding on post-
mortem.  The  A&E  staff  are  very  aware  of  the  signs  of  a  pituitary  tumour,  and  aside  from 
depression  which  she  had  suffered  for  some  time,  she  showed  no  other  symptoms  of  a 
tumour. 

As  an  aside,  this  case  was  discussed  in  the  Trust’s  Mortality  meeting  and  the  general 
consensus was that management was appropriate in accordance with NICE guidance. The 
inquest did highlight issues with documentation, it was not of an optimal standard and not in 
line with GMC Good Medical Practice guidance. We have presented this to the Junior Doctors 
on their trust induction as well to ensure that notes are accurately recorded and not ‘copy and 
pasted’. 

2.  Concerns  that  no  structured  neurological  observations  were  undertaken  on  a 
patient presenting with such a low GCS, risking deterioration being missed. 

The  Trust’s  letter  in  August  2025  showed  how  Mrs  Heaver’s  GCS  improved  rapidly  during 
transport (after the bolus of Naloxone) and then upon admission to hospital. However, review 
of the notes identified the need for improved documentation of neurological observations. The 
case  identified  the  need  for  standardised  and  frequent  GCS  documentation.  The  Trust’s 
Deteriorating Patient Lead Nurse has reviewed the notes and implemented improvements to 
the Trust’s electronic documentation system. 

Digital improvements  

The Sunrise digital system currently used within the Trust records patient documentation and 
clinical observations via electronic flowsheets. At present, neurological assessment within the 
observation  flowsheet  requires  clinicians  to  record  alertness  using  the  ACVPU  scale  in 
alignment  with  National  Early  Warning  Score  2  (NEWS2).  Where  an  abnormal  alertness 

 
 
 
 
 
 
 
 parameter is entered (i.e. any response other than “Alert”), the system prompts the user to 
indicate whether a Glasgow Coma Scale (GCS) assessment is required. However, even when 
a  clinician  confirms  that  a  GCS  assessment  is  clinically  indicated,  completion  of  the  GCS 
remains non-mandatory, and observations may be submitted without this assessment being 
recorded. Furthermore, the current configuration requires the clinician to manually locate and 
complete  the  GCS  assessment  further  down  within  the  flowsheet,  which  introduces  risk  of 
omission during time-critical situations. 

In response to these identified risks, the Deteriorating Patient Lead Nurse has co-designed a 
revised digital deteriorating patient pathway as part of a wider system enhancement. Under 
the  proposed  changes, where  a  clinician  indicates that  a GCS  assessment  is required, the 
assessment will automatically become visible and directly accessible within the observation 
workflow.  In  addition,  completion  of  the  GCS  will  be  mandated  before  submission  of 
observations  where reduced  consciousness  is  documented  and GCS  completion  has  been 
selected.  These  changes  are  intended  to  reduce  the  potential  for  human  error,  ensure 
compliance  with  neurological  assessment  standards,  and  enhance  patient  safety  during 
episodes of clinical deterioration. 

Separately, the Sunrise system is scheduled to upgrade from Version 21.1 to Version 25 (V25) 
by Summer 2026. The digital deteriorating patient pathway, including the revised neurological 
observation  functionality,  is  due  to  be  completed  and  submitted  for  system  testing  during 
Quarter  One  (April–June)  2026.  Subject  to  successful  testing  and  governance  approval, 
implementation of the updated pathway may occur prior to the full V25 system upgrade, with 
formal go-live dates to be confirmed following completion of testing. 

Policy updates  

In addition, as mentioned in the Trust’s letter in August 2025, the Vital Signs Policy has been 
reviewed  and  updated  effective  from  November  2025.  This  revision  incorporates  specific 
learning identified from the incident involving Mrs Heaver and reflects the Trust’s commitment 
to  continuous  improvement,  education,  and  the  embedding  of  best  practice  into  clinical 
governance frameworks. 

The following amendments have been incorporated into the Policy: 

Section 9.3 
The  medical  team  must  be  informed  of  any  change  in  a  patient’s  neurological  condition, 
specifically a deterioration of two points in the Glasgow Coma Scale (GCS). A patient with a 
GCS  of  9  or  less  may  require  intubation  to  protect  their  airway  and  to  support  effective 
ventilation. Consideration must be given to referral to Critical Care Outreach and/or the Critical 
Care Team. 

Section 9.7 
Patients  receiving  Naloxone  infusions  are  required  to  undergo  observations,  including 
neurological assessment, every fifteen minutes for the first hour following commencement of 
the  infusion  and  thereafter  every  thirty  minutes  until  a  medical  decision  has  been  made  to 
discontinue  the  infusion,  in  accordance  with  guidance  issued  by  the  Royal  College  of 
Emergency Medicine (2024). 

While this level of escalation did occur in Mrs Heaver’s case, where a naloxone infusion was 
recommended following review by Critical Care Outreach team, the Trust has now formally 
embedded this requirement within local policy. This ensures that learning from the incident is 
translated 
thereby  strengthening  consistency, 
accountability, and patient safety across all clinical areas. 

into  explicit  standards  of  practice, 

 
 
 
 
 
 
 
 
 
 Furthermore, the inclusion of guidance from the Royal College of Emergency Medicine (2024) 
within  the  revised  policy  reinforces  alignment  with  national  evidence-based  standards  and 
supports the delivery of best practice in the management of Naloxone infusions. This reflects 
the  Trust’s  commitment  to  maintaining  gold-standard  care  in  accordance  with  nationally 
recognised clinical guidance. 

Importantly, this policy update is not solely procedural amendments but are actively embedded 
within the Trust’s education and training infrastructure. The revised standards now inform and 
support the following programmes: 

  ALERT Course 

A nationally recognised course utilising a structured and prioritised approach to 
patient assessment and management. It promotes early recognition of clinical 
deterioration, proactive intervention, and effective management of acute illness. 

  Resuscitation Training – Immediate Life Support (ILS) 

The Trust’s Immediate Life Support course is accredited by the Resuscitation Council 
UK and is designed for healthcare professionals involved in the early recognition and 
management of acutely / critically ill patients. This includes practical, simulation-
based training to reinforce the assessment and escalation of deteriorating patients, 
including those with reduced or fluctuating GCS. 

  Governance Meetings 

The revised policy will be formally presented at Urgent, Emergency, and Acute 
Medicine governance meetings by the Consultant team. This ensures that clinical 
expectations and gold-standard practice in the assessment, escalation, and 
management of patients with reduced or fluctuating GCS are clearly communicated 
and understood across relevant specialties.  

3.  Throughout this investigation I was presented with inconsistent, unreliable and 
incomplete medical records. This significantly hindered my ability to investigate 
the death and creates a risk of future patient harm. 

The coroner will be aware that the legal services department in the Trust was under immense 
pressure  last  year  when  this  inquest  was  opened  and  concluded.    There  was  high  staff 
turnover  and  the  department  was  not  running  effectively.  A  review  of  the  file  notes  that 
numerous requests were made by the coroner’s officers for the medical records and imaging 
but this was unfortunately not sent in a timely manner. This caused the inquest to be adjourned 
and  caused  distress  to  the  family.  The  Trust  apologises  for  this.  The  team  is  evolving  and 
undergoing a period of transformation to ensure that communication happens promptly. We 
have  put  in  stringent  Standard Operating  Procedures (SOP’s),  Key  Performance Indicators 
(KPI’s)  and  introduced  case  handlers  for  each  inquest  to  ensure  that,  from  the  offset,  key 
information  is  provided  to  the  coroner  and  the  officers.  We  have  been  praised  on  the 
improvements that have taken place since July 2025 and we will continue to ensure we are 
efficient with our communication.  

4.  I am concerned that the 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, particularly over band holidays. 

We believe that this was an issue that arose at the inquest itself and KPMT will respond to this 
in full. 

 
 
 
 
 
 
 
 
 
 We hope that the changes and learning that has taken place reassure the corner that we have 
taken steps to mitigate this sad case repeating itself and the Trust will continue to highlight 
this case in learning situations.  

Yours sincerely 

Acting Chief Executive

Ms Sarah Clarke 

Kent and Medway Coroners' Service  

Oakwood House  

Oakwood Park  

Maidstone  

Kent 

  8AE 

Chief Executives Office 

Priority House 

Hermitage Lane 

Maidstone 

Kent 

ME16 9PH 

6 March 2026 

Dear Ms Clarke 

Inquest into the death of Mrs Sarah Heaver 

Kent and Medway Mental Health Trust Response to the Regulation 28 Report to 

Prevent Future Death 

I write in response to the Regulation 28 Report dated 9 January 2026, sent to Kent and 

Medway Mental Health NHS Trust (the Trust) following the conclusion of the inquest into the 

very sad death of Mrs Heaver.  

In your report to the Trust, you raised the following matter of concern: 

I  am  concerned  that  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, particularly over bank holiday periods 

Mrs Heaver’s care was transferred to the care of the Home Treatment Team (HTT) which is a 

service provided when considering the least restrictive option in accordance with the Mental 

Health Act.  The aim of the HTT is to provide an individualised plan of care  for the patient in 

the  community  with  the  view  of  negating  the  need  for  a  hospital  admission.  The 

multidisciplinary team consists of nurses, occupational therapists, doctors, support, time and 

recovery workers and non-medical prescribers. 

 
 
 
 
 
 At the time of the inquest of Mrs Heaver, the Trust had already identified that there was a lack 

of consistent cover provided for prescribing over weekends. This was identified by the Service 

Manager in February 2025, when it became apparent that all 3 Independent prescribers were 

on  annual  leave  at  the  same  time.  This  had  unfortunately  occurred  due  to  2  of  the  3 

undertaking additional training at university and they had not been able to utilise their leave in 

line with Trust policy. As a trust we will ensure this situation does not arise again. At the time 

of identifying this shortfall in regards to appropriate prescribing cover, in consultation with the 

three  independent  prescribers  and 

,  Consultant  Psychiatrist,  it  was  agreed  that 

there  would  be  a  change  in  working  pattern  for  the  three  independent  prescribers 

subsequently working on a three-week rolling rota.  

The responsibility for appropriate booking and agreement of annual leave was also transferred 

from the medical staff and was added to the rostering responsibility of the Operational Team 

Managers.  This has now become established practice. All 3 prescribers now provide cross 

cover for  both teams on  all  weekends, bank  holidays, annual  leave or  sickness and  this  is 

reviewed in the teams total staffing cover weekly by the Operational Team managers. It has 

been agreed that if required, NHS Professionals can be utilised to provide prescribing cover, 

if the need should arise.  

In the event that that there are complexities outside the skill sets and role of the independent 

Nurse prescriber, there is 24 hr access to the on-call psychiatrist, who in turn can contact the 

on-call pharmacist to discuss, if required. 

I am sincerely sorry for the shortfalls in the care provided to Mrs Heaver. 

Thank you for bringing your concerns to my attention and I hope this provides you a level of 

assurance of the Trusts ongoing commitment in providing safe care to our service users. 

Please do let me know if I can be of any further assistance. 

Yours sincerely 

Chief Executive