The 4 day long inquest touching the death of Mrs Corrine Haslam concluded today with the Coroner finding that Mrs Haslam died of natural causes.  The significant causative factor was underlying heart disease which was worsened by her COPD and development of a pulmonary embolism.  The Coroner did not find that there were any failures that more than minimally contributed to death but did express concerns that had arisen during the course of hearing the evidence.

The Coroner is concerned that nursing staff on Taylor Ward at Tameside General Hospital do not appear to have available to them a clear and unambiguous policy on VTE (blood clot in the vein) assessments, and when these should be completed and reviewed.  The Coroner is going to make a prevent of future deaths report to the CEO of Pennine Care NHS Foundation Trust in this regard.

The Coroner was also concerned by the absence of a unified record keeping system between Acute Healthcare Trusts, Primary Care and Mental Health Trusts.  He commented that such a system would avoid the need for work arounds to transmit information between them regarding a patient’s healthcare.  It would also ensure that there was one place for observations and monitoring record keeping.  The Coroner is issuing a Prevention of Future Deaths report to the Secretary of Statement for Health and Social Care in this regard.

We will share the PFD reports once these have been issued by the Coroner.

Ison Harrison are proud to be able to contribute to making changes and improvements to our healthcare system to help reduce the risk to patients and improve patient care.

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