Corinne Haslam
PFD Report
Partially Responded
Ref: 2023-0266
Coroner's Concerns (AI summary)
Barriers to physical health input for mental health patients, incompatible electronic record systems, and unclear VTE risk assessment guidance for ward staff pose significant patient safety risks.
View full coroner's concerns
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.
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.
Responses
Noted
The Department acknowledges concerns over physical healthcare in mental health settings and compatibility of electronic patient records, noting expectations for the Trust's response and describing the use of shared care records in Greater Manchester. (AI summary)
The Department acknowledges concerns over physical healthcare in mental health settings and compatibility of electronic patient records, noting expectations for the Trust's response and describing the use of shared care records in Greater Manchester. (AI summary)
View full response
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.
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.
Sent To
- Department of Health and Social Care
- Pennine Care NHS Foundation Trust
Response Status
Linked responses
1 of 2
56-Day Deadline
15 Sep 2023
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
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.
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.
Copies Sent To
together with and Weightmans LLP. the Care Quality Commission and Tameside Metropolitan Borough Council
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.