Catherine Kirkham

Coroner's concerns

Coroner’s Concerns (source excerpt)

The first concern relates to the accessibility and usability of systems used by hospital clinicians to access GP records. Evidence indicated that entries within these systems are extensive and not easily navigable, making it difficult to identify key information such as a patient’s vaccination status.

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The first concern relates to the accessibility and usability of systems used by hospital clinicians to access GP records. Evidence indicated that entries within these systems are extensive and not easily navigable, making it difficult to identify key information such as a patient’s vaccination status. The absence of a dedicated vaccination tab was highlighted as a barrier. Although some local work is underway to improve triage systems, prompting clinicians to check and document vaccination history when wound-related issues are identified, there is uncertainty as to whether such improvements are implemented consistently across hospitals nationally. The second concern relates to deficiencies in clinical documentation and decision-making during Mrs Kirkham’s care at Tameside General Hospital. Specifically, the treating doctor failed to record a clear clinical diagnosis and did not document the administration of a tetanus booster, despite later stating he believed it had been given. Further concerns arose regarding the prescription of oral antibiotics without conducting a swallow assessment in a patient presenting with swallowing difficulties and lockjaw. This omission contributed to a subsequent choking incident at home and prevented the opportunity for hospital admission and intravenous treatment. The third concern relates to missed opportunities across multiple points of care to identify tetanus risk and provide appropriate treatment. These include failures in the Urgent Treatment Centre, Emergency Department, and in the GP referral. Given that tetanus vaccination is typically administered in secondary care, it is essential that referrals clearly highlight suspicion of tetanus. Earlier intervention may have significantly improved the patient’s chances of survival.

Responses 1 respondent

Department of Health and Social Care

Central Government PDF ↗

AI-generated response summary

The Department of Health and Social Care acknowledged the report and mentioned broader government plans for IT improvements, including shared care records and a Single Patient Record. However, they have deferred the specific concerns raised to NHS England, who will provide a full response.

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Dear Ms Gill, Thank you for the Regulation 28 report of 17 June 2026 sent to the Department of Health and Social Care about the death of Catherine Kirkham. I am replying as the minister with responsibility for primary care. Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Kirkham’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are deeply concerning, and I am grateful to you for bringing these matters to my attention. The report raises concerns over the operability of IT systems used by doctors in secondary care to access GP patient records, the failure to accurately record clinical information relating to Mrs Kirkham’s visits to Tameside General Hospital, and the several missed opportunities to diagnose and treat Mrs Kirkham for tetanus. In preparing this response, my officials have made enquiries with NHS England and the UK Health Security Agency to ensure we adequately address your concerns. The 10-year health plan sets out our commitment to making improvements at the interface between primary and secondary care. This includes work to improve IT through initiatives such as increasing access to shared care records and developing greater interoperability of electronic patient records (EPRs). In addition, the government is proposing a Single Patient Record (SPR) to unify patient data from multiple sources into one easy-to-access platform for patients and clinicians. By creating a single or unified health record, that is more navigable, clinicians will have the data they need when treating patients. Frontline staff will be able to make more informed decisions, reducing risk. It is the responsibility of the UK Health Security Agency (UKHSA) to maintain and update public health guidance, including on the need for ascertaining an individual's vaccination status following a potentially tetanus-prone wound. However, it is the responsibility of NHS B1

[Page 2] England to ensure this guidance is implemented, including the design of triage systems and the use of prompts and decision-support mechanisms. In considering your report, officials within the Department of Health and Social Care have made enquiries with NHS England and concluded that NHS England are better placed to address your concerns directly. I am advised that NHS England will therefore provide you with a full and comprehensive response on the concerns you have raised. I hope this response is helpful. Thank you again for bringing these concerns to my attention.

Report sections

Investigation and inquest

On 7 March 2025, I commenced an investigation into the death of Catherine Kirkham, aged 82 years, who died at Willow Wood Hospice. The investigation concluded at the end of a jury inquest on 23 April 2026. A jury inquest was required as tetanus is a notifiable disease. The jury reached a narrative conclusion that Mrs Kirkham died following complications arising from tetanus which was first diagnosed and treated following her third attendance at hospital.

The medical cause of death was: 1a) Pneumonia 1b) Tetanus II) Ischemic heart failure, COPD

Circumstances of the death

Catherine sustained an unwitnessed fall at her home address on 14 February 2025. She presented to her GP on 19 February 2025, with wounds to lower limbs and a necrotic toe. She was referred to A&E, where she was seen by an Emergency Nurse Practitioner. Her wounds were cleansed and dressed. She was given antibiotics and referred to the District Nursing Team, however Mrs Kirkham’s tetanus status was not checked, and a tetanus vaccination was not provided. On 26 February 2025, Catherine re-presented to the Emergency Department with lockjaw and difficulty swallowing. After examination and observations Catherine was given antibiotics for cellulitis. Tetanus was discussed and dismissed. Catherine was sent home, despite Mrs Kirkham’s son raising the possibility of tetanus with the doctor in the Emergency Department. We heard that despite Mrs Kirkham having difficulty swallowing she was prescribed oral antibiotics. On 28 February 2025 Mrs Kirkham’s daughter urgently tried to arrange a liquid form of the antibiotics from her GP as her mother’s teeth were clenched and it was difficult to open her mouth. Mrs Kirkham’s symptoms worsened, including difficulty breathing, so she returned to hospital by ambulance. Mrs Kirkham was admitted and diagnosed with tetanus, COPD, sepsis and pneumonia. This is the first time Mrs Kirkham was treated for tetanus. On 1 March 2025 Mrs Kirkham suffered two heart attacks. Due to Mrs Kirkham’s clinical condition deteriorating a decision was made to commence end of life care. On 4 March 2025 Mrs Kirkham was transferred to Willow Wood Hospice and died shortly thereafter.

Action should be taken

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.

Coroner's concerns

Responses 1 respondent

Department of Health and Social Care

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