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Sophie Watson acts for family in inquest into the preventable death of Miss Maureen Durkin contributed to by neglect

<!-- wp:paragraph --> <p>Miss Durkin was a 68 year old woman who tragically died following a bowel perforation which led to septicaemia. Following an inquest at Bolton Coroners Court, Assistant Coroner John Pollard found that the care provided by the hospital fell below the level expected in all major hospitals and concluded that Miss Durkin’s death was due to natural causes contributed to by neglect.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>Miss Durkin underwent a CT scan which was reported 7 days later, and stated Miss Durkin had a bowel tumour. Upon receipt of the report, the hospital called in Miss Durkin immediately for emergency surgery.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>On arrival to the hospital, on 28.04.23, the clinicians decided Miss Durkin required surgery to insert a stent. However, due to unavailability of the clinicians to perform this over the bank holiday weekend, the surgery was delayed.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>On 02.05.23 it was recognised the scan had been reported incorrectly and in fact demonstrated a stricture secondary to diverticular disease which required alternative treatment.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>That day Miss Durkin’s bowel perforated, and she underwent emergency surgery. Miss Durkin was subsequently admitted to the Critical Care Unit where she sadly died.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The coroner referred to clinicians’ evidence that, had Miss Durkin’s scan been accurately reported on 21.04.23 and the correct treatment been instituted thereafter, she would have survived.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The coroner found the care provided by the Trust fell below the level expected in all major hospitals.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>In assessing whether there was neglect, the coroner found:</p> <!-- /wp:paragraph --> <!-- wp:list {"ordered":true,"type":"lower-alpha"} --> <ol style="list-style-type:lower-alpha"><!-- wp:list-item --> <li>there was a known condition for which action was needed;</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>there was a failure to properly examine the scan of 21.04.23 which amounted to a gross failure; and</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>that failure to act had a clear and direct causal connection to Miss Durkin’s death.</li> <!-- /wp:list-item --></ol> <!-- /wp:list --> <!-- wp:paragraph --> <p>The conclusion was that of natural causes contributed to by neglect.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>Sophie was instructed by Lauren Dale of Hudgells Solicitors.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>Sophie Watson is a member of the Inquests and Inquiries Team at Parklane Plowden Chambers and regularly acts on behalf of Interested Persons at Inquests. Sophie’s full profile can be accessed <a href="file:///C:/Users/Victoria.Steele/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/FYP7RB9X/(https:/www.parklaneplowden.co.uk/our-barristers/sophie-watson/">here</a>.</p> <!-- /wp:paragraph -->

Third Party Harassment: An Update

<!-- wp:paragraph --> <p>Some readers may have attended a <a href="https://www.parklaneplowden.co.uk/replay-third-party-harassment-28-september-2023/">Law with Lunch seminar on 28<sup>th</sup> September 2023</a> during which <a href="https://www.parklaneplowden.co.uk/our-barristers/roger-quickfall/">Roger Quickfall </a>and <a href="https://www.parklaneplowden.co.uk/our-barristers/bryony-clayton/">Bryony Clayton</a> discussed third party harassment and the law as it was, the law as it is and the law as it may be.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>It may be recalled that the position prior to 1<sup>st</sup> October 2013 was that there was an obligation on employers to prevent third party harassment. Liability would attach if the Respondent failed to take such steps as would have been reasonably practicable to prevent the third party from harassing the Claimant.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>After 1<sup>st</sup> October 2013, there was no liability on employers for third party harassment, following the repeal of sections 40(2)-(4) Equality Act 2010 (‘EqA 2010’). The duty to take steps to prevent harassment was removed. The Court of Appeal in <em><u>Unite the Union v Nailard</u></em> 2019 ICR 28, CA confirmed that neither section 13 nor section 26 EqA 2010 covered liability for third party harassment, concluding that had parliament intended this it would have been done explicitly.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The Workers Protection (Amendment of Equality Act 2010) Bill is currently passing through parliament. The background to the bill is as follows:</p> <!-- /wp:paragraph --> <!-- wp:list --> <ul><!-- wp:list-item --> <li>It was introduced by Liberal Democrat member for Bath, Wera Hobhouse on 15<sup>th</sup> June 2022 and was prompted by the MeToo campaign and the President’s Club scandal;</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>In 2018 the House of Commons Women and Equalities Select Committee conducted an enquiry into sexual harassment in the workplace. This criticised the gaps in, and enforcement of, protections from workplace harassment. The committee recommended new legislation to impose a new employer liability duty for third party harassment and general duties to prevent harassment that could be enforceable by the Equality and Human Rights Commission (‘EHRC’);</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>A consultation was launched by the government in 2019 on sexual harassment in the workplace to consider, amongst other proposals, the introduction of a mandatory preventative duty that requires employers to protect workers from harassment in the workplace and introduction of explicit employer liabilities for third party harassment;</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>In 2020 the Government Equalities Office’s own survey on sexual harassment in the workplace found that nearly a third of all employees surveyed had experienced some form of sexual harassment in their workplace or work-related environment in the previous 12 months;</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>The government response to the consultation was published in July 21. The consultation findings were broadly supportive and the government committed to introduce new measures alongside a new EHRC statutory code of practice on workplace harassment;</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>The proposal was that a claim could be brought after a single incident of harassment as opposed to previous three strikes formulation whereby employers needed to know of two previous incidents of third party harassment before they could be liable. It was proposed that there was an ‘all reasonable steps defence’ proposed.</li> <!-- /wp:list-item --></ul> <!-- /wp:list --> <!-- wp:paragraph --> <p>The bill passed through the House of Commons with cross party support during 2022. The draft bill proposed:</p> <!-- /wp:paragraph --> <!-- wp:list {"ordered":true,"type":"1"} --> <ol type="1"><!-- wp:list-item --> <li>An amendment to section 40 EqA 2010 which inserted subsection 1A – this proposed a general liability for actions of third parties which constituted harassment where all reasonable steps had not been taken;</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>The insertion of section 40A which imposed a duty on employers to prevent sexual harassment of employees. This would be enforceable in the tribunal and by the EHRC;</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>The insertion of section 124A into the EqA 2010 which allowed for an uplift of up to 25% on damages in the employment tribunal where there has been a failure to prevent harassment or sexual harassment.</li> <!-- /wp:list-item --></ol> <!-- /wp:list --> <!-- wp:paragraph --> <p>By the time the bill reached the House of Lords, there had been a government amendment to address issues of free speech. This was intended to clarify for the employer and employment tribunal that employers were not, for example, required to shut down valid conversations or expressions of opinion between customers in a pub. There was a much lengthier clause 1 which provided that the employer was not liable for third party harassment if:</p> <!-- /wp:paragraph --> <!-- wp:list {"ordered":true,"type":"a"} --> <ol type="a"><!-- wp:list-item --> <li>The conduct constituting harassment involved a conversation in which the Claimant is not a participant or a speech which is not aimed at the Claimant;</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>The conversation or speech involved expression of an opinion which was on a political, moral, religious or social matter,</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>The opinion expressed was not grossly offensive and</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>The expression of the opinion did not have the purpose of violating the Claimant’s dignity or of creating an intimidating, hostile, degrading, humiliating or offensive environment for the Claimant.</li> <!-- /wp:list-item --></ol> <!-- /wp:list --> <!-- wp:paragraph --> <p>The first reading in the House of Lords took place on 6<sup>th</sup> February 2023. At the second reading on 24<sup>th</sup> March 2023, there was significant debate, lasting for about an hour and a half. Concerns were expressed that employers would have to stray into the private prejudices of their staff. Clause 1 (i.e. duty to prevent all forms of third party harassment) proved controversial. Those opposed to regulation of the employer/employee relationship generally considered that parties should be free to negotiate terms. Some argued that the old laws against incitement were said to be sufficient.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>An issue was also raised over the ‘<em>all</em> reasonable steps’ defence, it being suggested that this wording might be too onerous on smaller employers. Baroness Scott of Bybrook tried to address the issue of ‘all reasonable steps’ by explaining that the concept has been in the EqA 2010 since its inception in the context of employer’s liability and that it is well understood by employers and employment tribunals and is nothing new. What is reasonable, she said, is a question of fact for the tribunal. Factors include the work environment, the size of the organisation and known risk factors, as well as cost and practicality. She made the point that what constitutes all reasonable steps is not defined in law and we do not intend to do so as this would remove the flexibility to take a proportionate response based on individual circumstances of the workplace. The EHRC Code of Practice would offer some guidance on this to employers.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>There was a third reading in the Lords on 12<sup>th</sup> September 2023, following amendments to the bill. At that time clause 1 has been deleted entirely (such that there would be no duty to prevent harassment related to protected characteristics other than sex). ‘All’ had been removed from the ‘all reasonable steps’ defence. The uplift to compensation provisions remained.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>On 20<sup>th</sup> October 2023, the bill returned to the House of Commons for consideration. In a brief discussion lasting only a few minutes, the Commons acknowledged the compromises that had been reached to get to this position and accepted the amendments made by the House of Lords. It therefore appears that the new legislation will <em>not</em> contain any provisions for third party harassment generally but will cover sexual harassment cases only.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The timescales for the implementation of the statute are not clear but, in any event, the provisions will not come into force until 12 months after Royal Assent to allow the EHRC time to develop a Code of Practice.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>Practitioners will need to keep abreast of the further progress of the bill. It seems likely that the new legislation will provide fertile ground for employment lawyers once in force.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p><strong>Update: The Workers Protection (Amendment of Equality Act 2010) Bill received Royal Assent on the 26 October 2023. </strong></p> <!-- /wp:paragraph -->

Bronia Hartley represents family of Melvyn Blount who took his life after the onset of an acute episode of mental ill-health

<!-- wp:paragraph --> <p><a href="https://www.parklaneplowden.co.uk/our-barristers/bronia-hartley/">Bronia Hartley</a>, instructed by <a href="https://www.leighday.co.uk/">Leigh Day</a>, represented the family of Melvyn Blount (known as Mel) who took his life after the onset of an acute episode of mental ill-health.  </p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>HM Assistant Coroner Susan Evans found that there were missed opportunities by Mel’s GP practice in the days before his death to explore whether he was suffering an acute psychotic episode, to refer him to the crisis team or A&amp;E and to warn his family not to leave him alone.&nbsp;These missed opportunities were found to have contributed to Mel’s death.&nbsp; </p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The Coroner issued a Prevention of Future Deaths report in relation to the GP surgery’s practices in relation to warning patients about the potential side effects of medication.&nbsp;The inquest heard that Mel was not told about a drug alert which included information relating to the potentially increased risk of suicidal ideation in patients taking the sedative/hypnotic sleep medication that he was prescribed four days before his death. </p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>Further detail can be found <a href="https://www.leighday.co.uk/news/news/2023-news/inquest-into-the-death-of-melvyn-blount-aged-64/">here</a>. </p> <!-- /wp:paragraph -->

Hari Menon successfully represents Claimant in Whistleblowing Case

<!-- wp:paragraph --> <p><a href="https://www.parklaneplowden.co.uk/our-barristers/hari-menon/">Hari Menon </a>successfully represents the claimant teacher in a whistleblowing case on appeal to the Employment Appeal Tribunal concerning the issue of when a supervening event, for which a third party is responsible, breaks the chain of causation for the claimant’s loss (novus actus interveniens).</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The claimant in a whistleblowing claim succeeded on liability, with the Employment Tribunal making a finding that her employers (both respondents) had made false allegations against her and used these as a basis for making a referral, in bad faith, to her professional body the General Teaching Council for Scotland (GTCS).</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The Employment Tribunal found that this was in retaliation for the claimant’s whistleblowing and was a detriment;&nbsp; further, that her dismissal by the 2nd respondent was also for this reason and automatically unfair. However, at the remedies hearing, the ET reduced the claimant’s compensation substantially on the basis that the decision of the GTCS, after initial investigations, to proceed with the referral, was a supervening event which broke the chain of causation of liability for the claimant’s loss.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The claimant successfully appealed this to the EAT, sitting in Edinburgh (Lord Fairley) which held that the ET’s conclusion that there was a supervening event was irreconcilable with its own findings of fact. On those findings by the ET, the referral to the GTCS by the employers was malicious and the decision of the GTCS to proceed with the referral was a natural and reasonable consequence of the employers’ wrongful act. The matter was remitted to the ET to reconsider issues relating to remedy in the light of the EAT’s decision.</p> <!-- /wp:paragraph -->

Inquests and the Fixed Recoverable Costs Reforms: To Be or Not to Be?

<!-- wp:paragraph --> <p>Access to representation in the inquest process in relation to costs recoverability presently hangs in the balance as the final government proposals following the July MoJ consultation on Fixed Recoverable Costs (FRC) are awaited. Amongst other issues, the recoverability of inquest costs in Fatal Accident Act cases is part of the FRC consultation.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The consultation opened on 21 July 2023 and closed recently on 08 September. The MoJ has indicated a provisional view that a new rule should provide that for cases allocated to the Fast Track and to the Intermediate Track, the costs of inquests should be separately recoverable to the FRC, and subject to assessment, if these costs were reasonable and proportionate.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The FRC will come into force imminently on 01 October for cases issued, or a cause of action accruing, after this date and there is still no decision in respect of a new or amended rule regarding the recoverability of inquest costs.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The consultation highlighted recognition by the MoJ that as part of any proper investigation process, an inquest will typically pre-date, and may (to an extent at least) enable the litigation.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>In the multi-track, where FRC will not apply, the costs involved in an inquest can be recoverable.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The MoJ has acknowledged as part of the consultation that without the addition of a new rule in the CPR to provide for the separate recoverability of inquest costs in FRC cases that the level of costs involved in the inquest will make the pursuit of any claim for compensation uneconomic.&nbsp; Indeed, in such circumstance if a bereaved individual’s claim is pursued, they will need to fund most of (if not all) of the costs involved in the representation at the inquest.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The MoJ welcomed general views on its proposals. The Bar Council and the Personal Injuries Bar Association (PIBA) provided a joint response indicating agreement with the MoJ that this is an issue which needs to be addressed and an amended rule should allow for inquest costs to be separately recoverable to FRC subject to assessment.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The joint response of the Bar Council and PIBA was that:</p> <!-- /wp:paragraph --> <!-- wp:list --> <ul><!-- wp:list-item --> <li>Inquests are an integral part of the process for investigating unnatural deaths and will inform and facilitate decisions taken about civil proceedings. The rules should allow for such costs to be recovered in a civil claim to which FRC applies, bringing the Fast and Intermediate Tracks into line with the Multi Track in which such costs are recoverable.&nbsp;</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>It would be wrong to be overly prescriptive in defining the cases when inquests costs ought to be recoverable. Those claims that may be made following an inquest are not limited to claims for dependency under the Fatal Accidents Act 1976. There will be claims on behalf of the estate under the Law Reform (Miscellaneous Provisions) Act 1934; and accidents involving fatalities which found claims for family and non-family members for psychiatric injury as primary and secondary victims. Claims involving the deaths of children and young adults can be complex, but the damages recoverable can be limited to the levels set out in the Fast and Intermediate tracks.</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>Many cases involving inquests will be complex, and they should fall outside both the Intermediate and Fast Tracks. The CPR have recognised that claims brought by dependants under the Fatal Accidents Act are complex, and these should be excluded from the Fast Track. The Bar Council would support a rule to that effect. The Bar Council is less sure about to what extent such cases should also be excluded from the Intermediate Track. There will be some cases when the facts of an inquest greatly assist the determination of civil liability, and admissions may be made, and judgment entered. These cases may be suitable for the Intermediate Track as a result. It is important that the CPR allow for inquest costs to be recovered in these circumstances.</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>The Bar Council appreciates that drafting such a rule is not straightforward but is particularly concerned that it is important the recoverability of inquests costs is dealt with promptly so such costs can be recovered when the new rules take effect on 01 October 2023.</li> <!-- /wp:list-item --></ul> <!-- /wp:list --> <!-- wp:paragraph --> <p>It is clear that implementation of FRC will have a significant impact on litigation. The MoJ has acknowledged that the FRC rules as currently drafted may impede solicitors’ ability to pursue claims, and therefore may equally impact on the future ability of bereaved families to obtain representation unless they are able to fund this, wholly or in part, themselves. Therefore the final outcome for the FRC proposals and the rules in relation to inquests are eagerly awaited.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p><em><a href="https://www.parklaneplowden.co.uk/our-barristers/leila-benyounes/">Leila Benyounes</a> is Head of the Inquests Team at Parklane Plowden Chambers and is ranked as a leading junior in Legal 500 and Chambers and Partners for Inquests and Inquiries. Leila’s full profile can be accessed </em><a href="https://www.parklaneplowden.co.uk/barristers/leila-benyounes"><em>here</em></a>.</p> <!-- /wp:paragraph -->

May Martin successful in claim for delayed diagnosis of lung cancer

<!-- wp:paragraph --> <p><a href="https://www.parklaneplowden.co.uk/our-barristers/may-martin/">May Martin</a> acted for the Claimant in a multi-track clinical negligence claim before HHJ Richardson.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>May was instructed by <a href="https://www.hudgellsolicitors.co.uk/our-people/chris-moore/">Chris Moore </a>of <a href="https://www.hudgellsolicitors.co.uk/">Hudgell Solicitors</a>.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p><strong>Factual Background</strong></p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The Claimant had successful surgery for lung cancer in 2014 and was to be subject to regular follow-up thereafter. After attending follow-up appointments for approximately a year, the Trust failed to send the Claimant a letter informing her of the date of her next appointment. As the Claimant was unaware that a further appointment had been made, she did not attend. The Trust then discharged the Claimant from its care. The Claimant had no further follow-up in respect of her lung cancer. &nbsp;</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>In 2019, the Claimant attended A&amp;E with acute shortness of breath. She was diagnosed with recurrent lung cancer and given a life expectancy of 18-24 months.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p><strong>Proceedings</strong></p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The Trust admitted that it had acted negligently in discharging the Claimant from its care. The claim was defended on causation grounds on the basis that, even with regular follow-up, the recurrence of the Claimant’s lung cancer would not have been diagnosed at an earlier stage.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The expert evidence in the case was that follow-up monitoring by way of chest x-ray would not have led to an earlier diagnosis, but that follow-up monitoring by way of CT scan would have led to an earlier diagnosis. The Trust’s case was that the Claimant would have received an annual chest x-ray and clinical examination. The Claimant’s case was that she would have been monitored by way of CT scan.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The experts agreed that if the recurrence had been detected earlier, the Claimant would have avoided hospital admission and treatment in 2019, but her prognosis and life expectancy would have remained the same.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p><strong>Judgment</strong></p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>HHJ Richardson found that the Claimant’s follow-up appointment in 2017 would have involved a chest x-ray and thus recurrence would not have been detected at that stage. However, the Judge also found that the Claimant would have mentioned that she was experiencing increasing shortness of breath at her appointment in 2017. There would have been investigations done into the shortness of breath, but not a CT scan at that stage.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The Judge found that, at the Claimant’s appointment in 2018, a further chest x-ray would have been undertaken. That chest x-ray would not have shown any abnormalities. The Claimant would again have mentioned the increasing shortness of breath which, by this point, had become considerably worse. At this stage, with the investigations in 2017 not having identified a cause of the shortness of breath, the Claimant would have been referred for a CT scan. The CT scan would have shown recurrence of the Claimant’s lung cancer and palliative treatment would have commenced shortly thereafter. The Claimant would therefore have avoided the further symptoms and need for hospital admission and treatment in 2019. &nbsp;&nbsp;&nbsp;</p> <!-- /wp:paragraph -->

Treating physical illness in mental health patients

<!-- wp:paragraph --> <p>Richard Copnall represented the family of Corinne Haslam at the inquest in March 2023.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The coroner has now issued a prevention of future death report to the Secretary of State for Health and Social Care.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The inquest explored the challenges typically faced by patients who are detained under the Mental Health Act (and in the care of NHS Trust A), but who also require treatment for a physical condition (provided by NHS Trust B).</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>In the present case, both trusts operated on the same site at Tameside Hospital, but from different buildings.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>Mrs Haslam suffered from a respiratory condition. On a number of occasions, Trust A’s doctors sent Mrs Haslam to Trust B’s A&amp;E department only for her to be discharged back to Trust A. On the final occasion, her condition deteriorated in A&amp;E and Mrs Haslam died.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The coroner’s report identified the following concerns:</p> <!-- /wp:paragraph --> <!-- wp:list {"ordered":true,"type":"a"} --> <ol type="a"><!-- wp:list-item --> <li>The difficulty faced by Trust A’s doctors in obtaining the input of Trust B’s doctors, without having to transfer the patient to A&amp;E;</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>A&amp;E departments are typically busy environments which may not be conducive to delivering care to patients experiencing severe and enduring mental illness;</li> <!-- /wp:list-item --> <!-- wp:list-item --> <li>Trust A and Trust B operate incompatible systems for their medical records which obstructed the transfer of information and is inherently risky.</li> <!-- /wp:list-item --></ol> <!-- /wp:list --> <!-- wp:paragraph --> <p>The division of care for physical and mental health conditions between two different NHS trusts is the norm and the difficulties highlighted in the coroner’s report are typical.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The Secretary of State’s response, which is required by 15 September 2023, is eagerly awaited.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>The prevention of future deaths report can be viewed <a href="https://www.judiciary.uk/prevention-of-future-death-reports/corinne-haslam-prevention-of-future-deaths-report/">here</a>.</p> <!-- /wp:paragraph --> <!-- wp:paragraph --> <p>Richard was instructed by <a href="https://www.isonharrison.co.uk/our-people/gareth-naylor/">Gareth Naylor</a> of Ison Harrison.</p> <!-- /wp:paragraph -->