Mrs Corinne Haslam was a mental health patient on Taylor Ward at Tameside Hospital operated by Pennine Care NHS Trust however, the acute medical care at the same hospital fell under the auspices of Tameside and Glossop Integrated Care NHS Foundation Trust.
Mrs Haslam, who was known to have schizophrenia, was initially admitted as a voluntary patient to Taylor Ward, Tameside General Hospital on the 16 January 2022 for treatment of her mental health alongside her diagnosis of COPD.
Following a drop in her oxygen saturation levels her condition deteriorated and she went into cardiac arrest.
Mrs Haslam died on 18th March 2022 at Tameside General Hospital, Ashton-under-Lyne. The inquest investigation 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
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.
The Coroner confirmed he would be making a Prevention of Future Deaths Report pursuant to his obligations under Regulation 28 of The Coroners and Justice Act 2009 and Part 7 of the Coroners (Investigations) Regulations 2013. The Regulation 28 Report has now been issued which highlights some concerns which we helped uncover during the course of the inquest.
The Coroner within his report has highlighted the following concerns:
- 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 conducive to delivering care for patients experiencing severe and enduring mental illness;
- 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.
These concerns have been raised to the Secretary of State for Health and Social Care.
- 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.
This concern has been raised with the Chief Executive of Pennine Care NHS Foundation Trust
A response must be provided by the 15 September 2023, and we will provide further updates as matters unfold.
The family were represented by our Director and Head of Inquests, Gareth Naylor who can be contacted on 0113 284 5014.
