Barbara Wingate

To: 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 Mrs Barbara Wingate.

Firstly, I would like to offer my condolences to the family and friends of Mrs Wingate.

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 Mrs Wingate’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.

2

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 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 Mrs Wingate 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 Mrs Wingate 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 Mrs Wingate died, KCC received an average number of referrals for people who were discharged back to their own home and the average time from referral to discharge for these individuals was 2.5 days.

Current processes and challenges and change made.

During this period Kent Enablement at Home were experiencing a high number of vacancies within the team, with a 30% vacancy factor which impacted on the referral to discharge time. A recruitment campaign and efficiencies created within referral processes has reduced this time 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 time that Mrs Wingate died, the average time for discharge to be facilitated from the time of referral to the Short-Term Pathways team was 5.3 days. 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 transport availability. These delays are reported in Medway Hospital’s No

3 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 Barbara Wingate

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 Barbara Wingate on 21st May 2025.

The Coroner raised the following concern(s):
1. Evidence heard at the inquest revealed that the resuscitation department where Mrs Wingate should have been admitted was full and the evidence indicated that this was and is almost a daily occurrence at the Trust. 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 the court heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital.

2. 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 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.

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 - Barbara Wingate

3. 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. 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 as seen in this case 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 Mrs Barbara Wingate.

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.

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.

Letter reference: 2026.02.10 PFD - Barbara Wingate

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.

[Page 1] To: Catherine Wood, Area Coroner for Kent County Council Kent, and Medway 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 Mrs Barbara Wingate. Firstly, I would like to offer my condolences to the family and friends of Mrs Wingate. 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 Mrs Wingate’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.

[Page 2] 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 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 Mrs Wingate 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 Mrs Wingate 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 Mrs Wingate died, KCC received an average number of referrals for people who were discharged back to their own home and the average time from referral to discharge for these individuals was 2.5 days. Current processes and challenges and change made. During this period Kent Enablement at Home were experiencing a high number of vacancies within the team, with a 30% vacancy factor which impacted on the referral to discharge time. A recruitment campaign and efficiencies created within referral processes has reduced this time 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 time that Mrs Wingate died, the average time for discharge to be facilitated from the time of referral to the Short-Term Pathways team was 5.3 days. 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 transport availability. These delays are reported in Medway Hospital’s No 2

[Page 3] 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 Barbara Wingate 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 Barbara Wingate on 21st May 2025. The Coroner raised the following concern(s):
1. Evidence heard at the inquest revealed that the resuscitation department where Mrs Wingate should have been admitted was full and the evidence indicated that this was and is almost a daily occurrence at the Trust. 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 the court heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital.
2. 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 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.

[Page 2] Letter reference: 2026.02.10 PFD - Barbara Wingate
3. 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. 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 as seen in this case 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 Mrs Barbara Wingate. 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. 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.

[Page 3] Letter reference: 2026.02.10 PFD - Barbara Wingate
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, Re: Regulation 28 Report to Prevent Future Deaths Ms Barbara Wingate Thank you for the regulation 28 report dated 10 February 2026. We acknowledge the Coroner’s concerns raised under Regulation 28 and recognise the serious implications for patient safety associated with delayed admissions and discharge pressures within the acute hospital setting. Medway Council fully accepts its responsibilities within the wider system and remains committed to taking both immediate and longer-term actions to address these issues. System Factors Contributing to Delay At any given time, it would be erroneous to conclude delays in hospital discharge can be attributed solely to adult social care or community health services. Evidence from across Medway demonstrates that delays arise from a range of interdependent factors across the health and social care system. These include:
• Internal patient flow within the acute hospital
• Bed availability
• Discharge planning processes
• Clinical decision-making
• Escalation arrangements
• Capacity constraints in community and social care provision While the acute trust has implemented a number of measures to improve patient flow, it is Medway Council’s view, it would not be accurate to conclude that all possible internal actions have been exhausted. Improvements continue at a system interface level, and this is recognised by partners and reflected in ongoing system-wide oversight arrangements.

[Page 2] Oversight and Assurance Due to ongoing challenges with patient flow at Medway Foundation Trust, the local health & social care system is supported by the Discharge and Admissions Group (DAG). The DAG, commissioned by the Department of Health and Social Care (DHSC), works with the most challenged systems to support improvement. It provides both practical support and constructive challenge in relation to discharge performance, admissions, and patient flow. Its remit includes the acute trust, Integrated Care Board (ICB), community providers, and the local authority, reflecting shared system responsibility. Additionally, the system benefits from 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 & social care capacity. Actions Taken and Ongoing A range of actions have been implemented or are in progress these are: Commissioning Actions Recommissioning of the Integrated Care and Reablement Service (ICRS) to increase community health bed capacity and support discharge from acute care. The Council has commissioned eight assessment beds for individuals ready for discharge but requiring further therapy to support independence before returning home. Introduction of 24-hour care at home services to support individuals with high needs to return home safely, where appropriate. Market Engagement The Council has recruited an independent commissioner to work with care providers to understand barriers to accepting discharged patients and to support increased residential and nursing home capacity, particularly for those with complex needs. System Leadership Appointment of a single care coordinator for hospital discharge, operating across the system and reporting directly to the Director of Adult Social Services. This role provides strategic oversight, coordination, and escalation across organisational boundaries, and operational linkage to the Chief Operating Officer at Medway Foundation Trust. Sourcing Care The Council has established a dedicated brokerage team focused solely on sourcing care for individuals ready to be discharged from hospital or community settings. Long-Term Capacity Development Medway Council is progressing through governance processes to develop a new 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 System partners recognise that improvement is required and that the risks identified stem from whole-system pressures. This is reflected in the Discharge and Admissions Group arrangements, which encompass all key partners, alongside a coordinated programme of immediate and long-term actions to improve patient flow, capacity, and safety. I hope the above clarifies the concerns raised.