Liam Sutton

To: Ms Catherine Wood, Area Coroner for 
Kent and Medway 

Kent County Council  
Corporate Complaints  
County Hall 
Maidstone, Kent 
ME14 1XQ 

RE: Regulation 28 Report to Prevent Future Deaths 

This report has been prepared in response to a request from the coroner for a 
Regulation 28 Report to Prevent Future Deaths dated 10 February 2026 in 
respect of the death of Mr Liam Andrew Sutton.  

Firstly, I would like to offer my condolences to the family and friends of Mr 
Sutton. 

Processes and challenges at the time of the death 

Kent County Council’s Short Term Pathways Team is a team of social care 
staff who support the hospital discharge pathways. The team works in 
partnership with Medway NHS Foundation Trust and based on a hub and 
spoke model, is part of the Integrated Discharge Team working at Medway 
Maritime Hospital. The team is also a partner in the Medway Hospital Transfer 
of Care Hub which is a system-level coordination point that includes a multi-
agency team of health, social care and voluntary sector agencies. 

KCC attends daily Transfer of Care Hub meetings, Monday to Fridays, where 
discussions take place regarding patients with the most complex discharge 
support needs to agree the most appropriate discharge pathway for those 
individuals.  

At the time of Mr Sutton’s death, KCC operated a Discharge to Assess model 
and home first approach in line with national statutory discharge guidance, 
Hospital discharge and community support guidance - GOV.UK. The Local 
Authority continues to operate this model. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 There is a significantly lower number of people leaving Medway Maritime 
Hospital from KCC’s boundary areas and with KCC commissioned support 
than from partner and neighbouring authorities. KCC typically receives an 
average of around 11 referrals per week to support people with discharge 
from Medway Hospital. This level of demand has remained consistent from 
the time preceding the death of Mr Sutton until present day.  

The number of bed days lost due to people occupying acute beds who have 
No Criteria to Reside attributable to KCC is typically below 5% of the total bed 
days lost at any given time. This has also remained fairly consistent from the 
time preceding the death of Mr Sutton until present day. 

Over 95% of people whose discharge is supported by KCC, are discharged 
back to their own home with an enablement service provided by Kent 
Enablement at Home. This is KCC’s in-house service that provides 
assessment and enablement support for people in their own home. 

For the particular week that Mr Sutton died KCC received almost twice the 
average number of referrals from Medway Hospital and the majority of these 
people were discharged home with a service delivered by Kent Enablement at 
Home.  

Current processes and challenges and change made. 

During this period, the team was running with a 20% vacancy factor. The 
vacancy factor combined with the increase in demand led to an increase in 
the time from referral to discharge for these people which was an average of 
3.8 days during the week that Mr Sutton died. A recruitment campaign and 
efficiencies created within Kent Enablement at Home’s referral processes has 
reduced the timescale for people discharged with home care support to 1.8 
days. This has been consistent for the last three months and is in line with key 
performance indicators set by Medway Hospital of a 48-hour timescale for 
discharge back to a person’s own home.  
A small number of people are discharged to a short-term bed where they 
receive a period of enablement and/or assessment of their longer-term care 
and support needs. The majority of these people are discharged to KCC’s 
Adult Short Stay Services which are in-house enablement beds. During the 
month of December 2024 when Mr Sutton died, KCC identified one person 
who required support from this pathway and the time for discharge to be 
facilitated from the time of referral was 6 days. Since the time of Mr Sutton’s 
death, improvements have been made to the referral processes for this 
pathway, and the current average transfer of care time is 3 days.  

Ongoing challenges beyond the control of the Council 

Despite the improvements made to the length of stay for people with No 
Criteria to Reside attributable to KCC, our data clearly shows that 50% of 
referrals experience delays beyond the control of KCC. The main reasons for 
these delays are availability of discharge documentation, medication, and 

2 

 
 
 
 
 
 
 
 
 
 transport availability. These delays are reported in Medway Hospital’s No 
Criteria to Reside report and KCC continue to work with the trust in identifying 
themes and trends that delay hospital discharge.  

Improvements identified  

KCC continues to review hospital discharge practice and guidance in 
collaboration with system partners. The local authority is currently undergoing 
a review of the Short-Term Pathways practice and processes, and the 
commissioning of hospital discharge services. KCC will continue to focus on 
the principles of Discharge to Assess and home first with the ambition of 
further increasing timely discharges into Pathway 1 home-based services.  

Yours sincerely, 

Corporate Director, Adult Social Care and Health 
Kent County Council 

3

Office of the Chief Nursing Officer 
NHS Kent and Medway 
2nd Floor, Gail House 
Lower Stone Street 
Maidstone 
ME15 6NB 

Private and Confidential 

Catherine Wood 
Area Coroner for Kent and Medway 
Kent and Medway Coroners' Service 
Oakwood House 
Oakwood Park 
Maidstone 
Kent 
ME16 8AE 

Sent via email 

7 April 2026 

Dear Ms Wood 

Regulations 28 and 29 Reports regarding Liam Andrew Sutton 

I write in response to the Prevention of Future Death Report dated 10th February 2026, sent 
pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 concerning the death 
of Liam Andrew Sutton 25th December 2024. 

The Coroner raised the following concern(s): 

1.  The  court  heard  at  the  inquest  revealed  that  the  resuscitation  department 
where Mr Sutton was admitted was busy and the evidence indicated that this 
was and is almost a daily occurrence at the Trust. Mr Sutton remained in the 
Emergency  department  resuscitation  area  for  longer  than  24  hours  and 
should instead have been transferred to a suitable bed in the hospital. The 
Intensivist  who  gave  evidence  was  clear  that  he  should  have  been 
transferred  to  the  High  Dependency/Intensive  Care  department  and  that 
patients who are admitted in a timely manner have a much better chance of 
survival. This also means that bays in the resuscitation department are not 
free to admit or attend to new acutely ill patients arriving at the hospital. 

2.  The  court  heard  that  the  main  issue  is  trying  to  discharge  a  patient  to  a 
suitable area in the hospital to free up a cubicle or bay in the resuscitation 
department. This in turn is due to beds being occupied by patients who are 
medically fit to be discharged. On any given day we heard that up to a third 
of the hospital beds can be filled with patients who are fit to leave hospital.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Letter reference: 2026.02.10 PFD - Liam Andrew Sutton 

3.  The court heard that the main delay is in discharging patients to appropriate 
settings or placements and the Trust have taken all steps they can internally 
to improve the flow of patients through the hospital. From the evidence the 
court heard it would appear that those responsible for providing care in the 
community  including  both  the  social  care  providers  and  the  community 
healthcare  providers  are  not  providing  either  timely  appropriate  care 
packages in the patient's home or a bed in an alternative placement be that 
a nursing home or residential home placement. The evidence suggested that 
where patients were self-funding the delays in discharge were less acute.  

4.  This means patients are kept in hospital for longer and thus are more at risk 
of contracting hospital acquired illness themselves which could lead to their 
own death but are also blocking beds which are needed to treat patients who 
require acute care in a suitable setting. This is leading to patients being kept 
longer in the emergency department and reducing available space to receive 
new critically ill patients. Both of these options can lead to death and there is 
clearly a risk of death for others requiring clinical care in an acute hospital 

I am responding on behalf of NHS Kent and Medway Integrated Care Board (ICB) to the 
concerns in your Regulation 28 and 29 reports. The concerns relate to the risk to critically unwell 
patients when emergency departments (EDs) are congested and transfer to an appropriate 
inpatient bed is delayed.  

NHS Kent and Medway takes your findings very seriously and we offer our heartfelt condolences 
to the family of Liam Andrew Sutton. 

While the majority of patients leave our hospitals when they are well enough to go home, we 
know more needs to be done to prevent the delays that some experience. These delays can be 
for a number of reasons from internal hospital processes to the complexity of arranging ongoing 
care before a patient can be safely discharged.  

I would like to outline the steps we have taken to reduce unnecessary bed occupancy by 
improving the discharge process and how ongoing support is organised.  

As you are aware, NHS Kent and Medway has a statutory oversight role in making sure providers 
of care, including acute hospital trusts, meet the standards set out in the NHS Constitution.  

The Medway Care Transfer Hub now acts as the single coordination and escalation point for the 
Local Authority and Health to support patients requiring new residential or nursing placements. 
This ensures consistent, person-centred decision making and removes delays associated with 
variable processes. The Hub provides weekly reports to the ICB on performance, issues, and 
escalations. 

Page 2 of 3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Letter reference: 2026.02.10 PFD - Liam Andrew Sutton 

Discharge pathways 

Over the last six months we have taken coordinated actions with Medway Council, Medway 
Foundation NHS Trust (MFT) and wider system partners to make several improvements to the 
main, nationally agreed pathways, which are used by the hospital for discharge. The pathways 
have been developed to address individual patient need and circumstances: 

1.  Strengthening same‑day discharge (Pathway 0, the national discharge definition, simple 
discharge home) – MFT have implemented a structured daily approach to maximise safe 
same-day discharge once a patient is deemed medically fit. This includes senior clinical 
review, early identification of patients suitable for discharge, and prompt resolution of 
simple barriers. This process is now fully operational and monitored through daily hospital 
management mechanisms. 

2.  Expanding the Home First/short‑term support capacity (Pathway 1, Discharge home with 
short-term support) – capacity for short-term care at home has been increased so more 
people can leave hospital safely with e necessary support. Oversight of capacity, flow and 
performance is provided through the Medway System Discharge Group, a local MDT 
approach supporting discharge. 

3.  Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing 

transfer delays – work is underway to expand access to short-term community 
rehabilitation beds improving onward flow for patients who no longer need acute inpatient 
care. A new bed-coordination (brokerage) function will be operational by quarter three of 
2026 ahead of winter with clear accountability for timely allocation and progress monitored 
monthly through ICB assurance routes. 

The ICB and MFT have also jointly identified a programme of work focused on reducing hospital 
avoidable delays for patients whose discharge is delayed by internal processes or hospital-based 
constraints. This work runs in parallel to the community pathway improvements described above.  

The Medway Care Transfer Hub now acts as the single coordination and escalation point for 
patients requiring new residential or nursing placements. This ensures consistent, person-centred 
decision making and removes delays associated with variable processes. The Hub provides 
weekly reports on performance, issues, and escalations.  

NHS Kent & Medway ICB acknowledges that delays in discharge increase the risk of harm for 
people waiting in the ED for specialist inpatient care. The actions set out above constitute the 
system’s agreed, time-bound programme reviewed with the national team on a quarterly basis to 
address those risks. Oversight arrangements ensure that delivery continues to be monitored 
closely, with escalation through formal governance routes where necessary.  

If you require any further information or clarification, I would be happy to provide this.  

Yours sincerely 

Chief Nursing and Quality Officer 

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