“Poor Quality Acute Physical Healthcare in the mental health setting Tammy’s death…”

The coroner’s concerns

1. Poor Quality Acute Physical Healthcare in the mental health setting Tammy’s death demonstrates a further example of a failure by medical staff to recognise a deteriorating patient and a subsequent delay in escalating for acute secondary care intervention. Her death comes after repeated concerns have been raised about the quality of the Trust’s physical healthcare service in secure settings since 2018 (when Angus Bowie died from sepsis due to a perforation), in 2019 (when Christopher Howard Smith died from a pulmonary embolus), in 2020 (when Alexander Braund died from a chest infection) and in 2021 (when Michelle Louise Whitehead died from Hyponatraemic Encephalopathy). At each of those inquests, the Trust committed to improving the quality of physical healthcare across all secure settings and yet the same poor quality has prevailed in Tammy’s care. These are examples of preventable deaths and the similarity in themes across them is exceptionally worrying. Action needs to be taken at the most senior level to effect meaningful change to the quality of physical healthcare across all secure settings at which the Trust provides services, recognising this class of patients as exceptionally vulnerable to deterioration as they are unable, either through mental health challenges and/or incarceration, to access healthcare services of their own volition. 2. Failure to Adhere to the National and Local National Early Warning Score (version 2) Policy This is a repeated theme identified at inquest and in previous Prevention of Future Death reports. Staff remained unclear at the inquest about how frequently vital signs ought to be taken, where and how to record the values, and what action should be taken depending on the score. 3. A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust. The policy needs to cover the assessment of risk when access is permitted to risk items, where such a risk assessment is stored and who is responsible for its review of content, what to do when ingestion is suspected including how this should be managed medically and what security measures need to be taken to locate the item. 4. Emergency Medical Calls There was significant confusion in this case as to who should call a medical emergency and how information should be relayed to the ambulance service. It had been recognised early in the day by the Security Team that Tammy may require an out of grounds medical transfer, but it was not until much later in the afternoon, when Tammy was in cardiac arrest, that an ambulance was called. The Security Team expected the physical healthcare team to place the call, the physical healthcare team expected the ward to place the call due to proximity to the patient. Evidence called at the inquest established continued confusion amongst staff as to how an emergency should be managed. This appears to be a training issue. Regulation 28 – After Inquest Document Template Updated 30/07/2020

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0017

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0