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.

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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

3 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.

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.

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

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.

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.

Dear Catherine Wood, Regulation 28 Report to Prevent Future Deaths Mr Liam Andrew Sutton We acknowledge the concerns by the Coroner under Regulation 28 and recognise the serious implications for patient safety arising from delayed admission and discharge pressures within the acute hospital setting. Medway Council fully accepts its responsibilities within the system and continues to be committed to taking appropriate action, both in the immediate term and over the longer term. System Factors Contributing to Delay At any given time, delays in discharge are not wholly attributable to adult social care or community health services. Evidence across Medway demonstrates that delays arise from a combination of interdependent factors across the health and social care system. These include acute hospital internal flow, bed availability, discharging planning processes, clinical decision making and escalation arrangements, alongside capacity constraints in community and social care provision. While the acute trust has implemented a range of measures to improve patient flow, it would not be accurate to conclude that all possible internal actions have been exhausted. Improvements continue at a system interface level, and this position is recognised across partners and underpins the ongoing whole system oversight arrangements described below. Oversight and Assurance Due to the persistent challenges with patient flow at Medway Foundation Trust, the local health & social care system has been supported by oversight through the Discharge and Admissions Group (DAG).

[Page 2] The DAG is commissioned by the Department of Health and Social Care to work with some of the most challenged systems to support improvement. It provides practical support and constructive challenge on discharge performance, admissions and patient flow; and includes the acute trust, ICB, community providers and the local authority within its remit, reflecting the shared system responsibility. In addition, the system has been supported by the DHSC commissioned Better Care Fund support programme, which provides sector led, whole system improvement support to strengthen integrated discharge arrangements, patient flow and the effective use of health and social care capacity. Actions Taken and in Progress Commissioning action: The council has recommissioned the Integrated Care and Reablement Service (ICRS). This will increase community health bed capacity to support discharge from acute care. Commissioning action: The council has commissioned 8 assessment beds to enable people who are ready to be discharged but not quite ready to go home to receive therapy and support them to independence. Commissioning action: The council has introduced 24-hour care at home to enable people who have high care and support needs to go home, rather than to a care home where it is safe and appropriate. Market engagement: The council has recruited an independent commissioner to work with private care providers to better understand why they are not accepting residents who are ready to be discharged from hospital, to determine how we can increase residential and nursing home capacity, particularly for people with complex needs. System Leadership: A single care co-ordinator for hospital discharge has been appointed to operate on a system basis and reports directly to the Director of Adult Social Services (DASS) providing strategic oversight, coordination and escalation across organisational boundaries and to the Chief Operating Officer at Medway Foundation Trust from an operational perspective. Sourcing Care: Medway Council has created a dedicated brokerage team to find care for people ready to be discharged from hospital and community health settings. This means that the team is not balancing the need to source care for people in the community at the same time. Long term capacity development: Medway Council is progressing through the governance process to develop an 80-bed care home, recognising ongoing system challenges. While a longer-term intervention, this reflects the Council’s seriousness in addressing structural capacity constraints.

[Page 3] Conclusion Partners across the system recognise that improvement is required and that the risks identified arise from whole system pressures. This is reflected in the Discharge and Admissions Group arrangements, which include the acute trust within their remit, alongside a programme of immediate and longer-term action to improve flow, capacity and patient safety.