Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0266, written 21 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jul 2023 |
|---|---|
| Reference | 2023-0266 |
| Deceased | Corinne Haslam |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Tameside and Glossop Integrated Care NHS Foundation Trust · Pennine Care NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: 1) Rt. Hon. Steve Barclay MP, Secretary of State for Health and
Social Care; 2)
, Chief Executive, Pennine Care NHS Foundation Trust
CORONER
I am Chris Morris, Area Coroner for Manchester South.
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 8th April 2022, I opened an inquest into the death of Corinne Haslam who died on 18th March
2022 at Tameside General Hospital, Ashton-under-Lyne, aged 55 years. The investigation concluded
with an inquest which I heard between 13th and 16th March 2023.
The inquest determined that Mrs Haslam died as a consequence of:-
1) a) Acute left ventricular failure;
b) Myocardial ischaemia and acute exacerbation of chronic obstructive pulmonary disease
c) Left ventricular hypertrophy
d) II) Pulmonary thromboemboli (treated); Agitation arising in the context of severe and enduring
mental illness
The conclusion of the inquest was one of Natural Causes.
CIRCUMSTANCES OF THE DEATH
Mrs Haslam died on 18th March 2022 at Tameside General Hospital, Ashton-under-Lyne, as a
consequence of complications arising from myocardial ischaemia and an acute exacerbation of
Chronic Obstructive Pulmonary Disease, against a background of undiagnosed left ventricular
hypertrophy. Mrs Haslam’s death was contributed to by physiological consequences of pulmonary
thromboemboli which had been treated, and agitation in the context of severe and enduring mental
illness.
Mrs Haslam was admitted to Taylor Ward, Tameside General Hospital in January 2022 following an
acute deterioration in her mental health which could not be safely managed in the
community. Whilst initially an informal patient, Mrs Haslam was subsequently detained under the
Mental Health Act.
Mrs Haslam reported a range of physical symptoms on the ward including chest pain and
breathlessness, and attended the Emergency Department at Tameside General Hospital on 7th
March 2022 when an acute exacerbation of COPD was diagnosed and treatment started.
On 13th March 2022, Mrs Haslam returned to the Emergency Department with similar symptoms,
and pulmonary thromboemboli were suspected due to abnormal blood results. Anticoagulant
treatment was prescribed and continued to be administered following Mrs Haslam’s return to Taylor
Ward.
On 17th March 2022, Mrs Haslam became breathless again and was initially managed on the ward by
means of monitoring, nebulisers and limited oxygen therapy. Following a significant deterioration at
around 22:00, Mrs Haslam was transferred back to the Emergency Department by ambulance, dying
there in the early hours of the following morning.
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion
there is a risk that future deaths will occur unless action is taken. In the circumstances it is my
statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
To the Secretary of State for Health and Social Care
1. The court heard evidence as to the barriers which exist and make it difficult for staff working
on mental health wards to obtain input from physical health specialists without sending a
patient to hospital via the Emergency Department.
Whilst there are occasions where review in an Emergency Department is most appropriate,
the court also heard evidence that these can be extremely busy and intensive environments
which may not be a conducive to delivering care for patients experiencing severe and
enduring mental illness;
2.
It is a matter of concern that Mental Health Trusts and Acute Trusts operate different
(apparently incompatible) electronic records systems. The absence of such a unified records
system creates obstacles as to the transfer of important clinical information between mental
health and physical health specialists (and vice versa), with an inherent risk to patient safety
arising from such information being held in silos.
To the Chief Executive of Pennine Care NHS Foundation Trust
3. It is a matter of concern that ward-based nursing staff do not appear to have been provided
with clear and unambiguous guidance as to the circumstances when a risk assessment for
Venous Thromboembolism (‘VTE’) should be undertaken following admission to a ward, and
the circumstances in which such risk assessment should be repeated.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
15th September 2023. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner,
and Weightmans LLP.
with
together
I have also sent a copy to the Care Quality Commission and Tameside Metropolitan Borough Council
who may find it useful or of interest.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may
send a copy of this report to any person who he believes may find it useful or of interest. You may
make representations to me, the coroner, at the time of your response, about the release or the
publication of your response by the Chief Coroner.
Dated:
21st July 2023
Signature: Chris Morris HM Area Coroner, Manchester South.
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health & Social Care 39 Victoria Street London SW1H 0EU 9 May 2024 Chris Morris Area Coroner 1 Mount Tabor Street Stockport SK1 3AG Dear Mr Morris, Thank you for your Regulation 28 report to prevent future deaths dated 21 July 2023 about the death of Corinne Haslam. I am replying as the Minister with responsibility for mental health and patient safety. Firstly, I would like to say how saddened I was to read of the circumstances of Corinne’s death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the significant delay in responding to this matter. Your report raises concerns over the provision of physical healthcare in a mental health setting and the compatibility of electronic patient records. I note that you have also addressed matters of concerns to the Chief Executive of Pennine Care NHS Foundation Trust and I would expect the Trust’s response to address those issues. In preparing this response, Departmental officials have made enquiries with NHS England. It is recognised that people living with severe mental illness are dying 15-20 years younger than the general population, largely from preventable or treatable physical illnesses. In particular people living with SMI are at much greater risk of cardiovascular disease. Therefore, it is essential that mental health settings meet patients' physical as well as mental healthcare needs either through their own appropriately qualified and experienced staff or in partnership with other providers. This requires mental health inpatient staff to be provided with adequate training and guidance on monitoring physical health, and importantly how to escalate and respond to concerns as needed. With regard to the compatibility of electronic patient records, a shared care record joins up information based on an individual rather than an organisation, and is a safe and secure way of bringing an individual’s separate records from different health and care organisations together. As of 2021 all primary and secondary care organisations have been able to share a subset of the patient information they hold – the core information standard – between providers within their own integrated care board footprint. Pennine Care NHS Foundation Trust and Tameside and Glossop Integrated Care NHS Foundation Trust are connected to the local instance of their shared care record (known as Greater Manchester). Future plans include making shared care records link together regardless of where you live or receive care in England. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MARIA CAULFIELD
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