Maureen Christy
PFD Report
All Responded
Ref: 2025-0561
All 1 response received
· Deadline: 31 Dec 2025
Coroner's Concerns (AI summary)
There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician confusion and policies not being consistently applied.
View full coroner's concerns
(1) The central policy or practice change with which this inquest was concerned was that pertaining to the testing of those designated as “Covid contacts”.
(2) The adoption and understanding of good policy and practice, serves to protect patients and to provide clinicians with an overarching framework within which to work. It provides clinicians with the security of knowing what is expected of them in their clinical practice.
(3) The policy change concerned was not acted upon in the case of the Deceased at the time of her being identified as a “Covid contact”. Notwithstanding the Trust’s recognition of the need to strengthen the dissemination of policy and practice changes, confusion around the dissemination of that policy or practice change, persisted to the time of evidence being given in this inquest.
(4) Whereas steps are already being taken to address the issue of the dissemination of policy and practice changes, this investigation has revealed matters giving rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, by reason of shortcomings in the dissemination of policy and practice changes pertaining to clinical care.
(2) The adoption and understanding of good policy and practice, serves to protect patients and to provide clinicians with an overarching framework within which to work. It provides clinicians with the security of knowing what is expected of them in their clinical practice.
(3) The policy change concerned was not acted upon in the case of the Deceased at the time of her being identified as a “Covid contact”. Notwithstanding the Trust’s recognition of the need to strengthen the dissemination of policy and practice changes, confusion around the dissemination of that policy or practice change, persisted to the time of evidence being given in this inquest.
(4) Whereas steps are already being taken to address the issue of the dissemination of policy and practice changes, this investigation has revealed matters giving rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, by reason of shortcomings in the dissemination of policy and practice changes pertaining to clinical care.
Responses
Action Planned
The Trust plans to roll out a digital solution called 'Alertive' from Q4 2025/2026 to send critical messages to staff with recorded acknowledgements, with future phases including policy document cascade beginning Q1 2026/2027. (AI summary)
The Trust plans to roll out a digital solution called 'Alertive' from Q4 2025/2026 to send critical messages to staff with recorded acknowledgements, with future phases including policy document cascade beginning Q1 2026/2027. (AI summary)
View full response
Dear Mr Holloway
Re: Regulation 28: Report to Prevent Future Deaths – Maureen Christy
Firstly, on behalf of Blackpool Teaching Hospitals NHS Foundation Trust, I would like to offer my sincere condolences to the family of Ms Maureen Christy.
Thank you for raising your concerns with us and please find below the Trust’s responses to the issues raised in the report to prevent future deaths.
1. The central policy or practice change with which this inquest was concerned was that pertaining to the testing of those designated as “Covid contacts”.
2. The adoption and understanding of good policy and practice, serves to protect patients and to provide clinicians with an overarching framework within which to work. It provides clinicians with the security of knowing what is expected of them in their clinical practice.
3. The policy change concerned was not acted upon in the case of the Deceased at the time of her being identified as a “Covid contact”. Notwithstanding the Trust’s recognition of the need to strengthen the dissemination of policy and practice changes, confusion around the dissemination of that policy or practice change, persisted to the time of evidence being given in this inquest.
4. Whereas steps are already being taken to address the issue of the dissemination of policy and practice changes, this investigation has revealed matters giving rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, by reason of shortcomings in the dissemination of policy and practice changes pertaining to clinical care.
Thank you for the opportunity to respond to the concerns raised. The Trust would like to acknowledge the seriousness of the issues highlighted and wish to provide context regarding the challenges faced during the COVID-19 pandemic and the steps taken to mitigate risks.
The COVID-19 pandemic presented unprecedented challenges for NHS hospitals. Guidance from national bodies evolved rapidly in response to emerging evidence and changing infection rates. This required hospitals to adapt operational practices at pace, often with very short implementation windows. Policies relating to infection prevention, patient care pathways, and staff safety were frequently updated, sometimes multiple times within a single week.
The speed and frequency of changes created significant operational pressures. Key challenges included:
• Volume and Complexity of Guidance: National directives were extensive and often required interpretation for local application.
• Rapid Dissemination: Ensuring all staff were aware of and understood new requirements in real time was critical but difficult given shift patterns and workforce pressures.
• Consistency of Practice: Maintaining uniform compliance across diverse clinical settings during periods of high demand was challenging.
To address these challenges, the Trust implemented a structured approach to policy dissemination:
• Central Coordination: A COVID-19 Response Group was established to review national guidance and translate it into local policy.
• Digital Communication Channels: Updates were cascaded via email bulletins, intranet alerts, and a dedicated COVID-19 resource hub accessible to all staff.
• Manager Briefings: Clinical and operational leads received daily briefings to ensure frontline teams were informed promptly.
• Safety Huddles and Ward Meetings: Key changes were reinforced through regular huddles and team meetings to support understanding and compliance.
• Training and Support: Where guidance required new clinical practices, rapid training sessions and e-learning modules were deployed.
Response
The Trust recognises the importance of learning from these experiences. Since the COVID pandemic, a number of refinements have been made to the Trust’s document control process, ensuring that these are reviewed, updated and approved within a robust process, and that new and updated documents are effectively communicated to staff.
Overseen by the Trust’s Audit and Clinical Effectiveness Committee, the Trust ensures that it has in place documents which are in date and appropriately risk stratified in terms of the critical content. When a document is approved following drafting or review, these are communicated to staff by e-mail via the Trust’s Team Brief which is co-ordinated by the Trust’s Communications Department. All policies are ratified through an appropriate committee attended by representation from our clinical divisions, with policy compliance reported back through our Audit and Clinical Effectiveness Committee. Divisions are supported by the relevant teams in the roll out of and changes that have a bearing on day to day process. An example of this would be the support offered to infection prevention and control nurses who guide the roll-out of any changes to the way we work and ensure appropriate oversight of IPC related policies and procedures.
The policies are then placed on the Trust’s intranet which is accessible to all staff. This includes the potential to search on key words / phrases etc to identify relevant policies and procedures. There is also a direct link between the Trust’s policies and the Trust’s corporate induction and mandatory training. This ensures that staff are appropriately trained and briefed on current practices.
The Trust has recognised that further steps could be taken in evidencing that staff have accessed and read all policies which are critical to their role. To create this enhanced oversight, the Trust has plans to roll out a digital solution from Q4 2025/2026 called ‘Alertive’, which allows key critical messages to be issued to all staff with staff acknowledgements of these messages recorded. Whilst the first phase of the implementation will focus on operational processes within the Emergency Department, future phases will include the scoping of the cascade of policy documents to staff, which will begin from Q1 2026/2027.
I hope this response provides you with the assurance you are seeking that the Trust has taken this matter seriously and that plans are in place to resolve the concerns raised.
If you require any further information, please let me know.
Re: Regulation 28: Report to Prevent Future Deaths – Maureen Christy
Firstly, on behalf of Blackpool Teaching Hospitals NHS Foundation Trust, I would like to offer my sincere condolences to the family of Ms Maureen Christy.
Thank you for raising your concerns with us and please find below the Trust’s responses to the issues raised in the report to prevent future deaths.
1. The central policy or practice change with which this inquest was concerned was that pertaining to the testing of those designated as “Covid contacts”.
2. The adoption and understanding of good policy and practice, serves to protect patients and to provide clinicians with an overarching framework within which to work. It provides clinicians with the security of knowing what is expected of them in their clinical practice.
3. The policy change concerned was not acted upon in the case of the Deceased at the time of her being identified as a “Covid contact”. Notwithstanding the Trust’s recognition of the need to strengthen the dissemination of policy and practice changes, confusion around the dissemination of that policy or practice change, persisted to the time of evidence being given in this inquest.
4. Whereas steps are already being taken to address the issue of the dissemination of policy and practice changes, this investigation has revealed matters giving rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, by reason of shortcomings in the dissemination of policy and practice changes pertaining to clinical care.
Thank you for the opportunity to respond to the concerns raised. The Trust would like to acknowledge the seriousness of the issues highlighted and wish to provide context regarding the challenges faced during the COVID-19 pandemic and the steps taken to mitigate risks.
The COVID-19 pandemic presented unprecedented challenges for NHS hospitals. Guidance from national bodies evolved rapidly in response to emerging evidence and changing infection rates. This required hospitals to adapt operational practices at pace, often with very short implementation windows. Policies relating to infection prevention, patient care pathways, and staff safety were frequently updated, sometimes multiple times within a single week.
The speed and frequency of changes created significant operational pressures. Key challenges included:
• Volume and Complexity of Guidance: National directives were extensive and often required interpretation for local application.
• Rapid Dissemination: Ensuring all staff were aware of and understood new requirements in real time was critical but difficult given shift patterns and workforce pressures.
• Consistency of Practice: Maintaining uniform compliance across diverse clinical settings during periods of high demand was challenging.
To address these challenges, the Trust implemented a structured approach to policy dissemination:
• Central Coordination: A COVID-19 Response Group was established to review national guidance and translate it into local policy.
• Digital Communication Channels: Updates were cascaded via email bulletins, intranet alerts, and a dedicated COVID-19 resource hub accessible to all staff.
• Manager Briefings: Clinical and operational leads received daily briefings to ensure frontline teams were informed promptly.
• Safety Huddles and Ward Meetings: Key changes were reinforced through regular huddles and team meetings to support understanding and compliance.
• Training and Support: Where guidance required new clinical practices, rapid training sessions and e-learning modules were deployed.
Response
The Trust recognises the importance of learning from these experiences. Since the COVID pandemic, a number of refinements have been made to the Trust’s document control process, ensuring that these are reviewed, updated and approved within a robust process, and that new and updated documents are effectively communicated to staff.
Overseen by the Trust’s Audit and Clinical Effectiveness Committee, the Trust ensures that it has in place documents which are in date and appropriately risk stratified in terms of the critical content. When a document is approved following drafting or review, these are communicated to staff by e-mail via the Trust’s Team Brief which is co-ordinated by the Trust’s Communications Department. All policies are ratified through an appropriate committee attended by representation from our clinical divisions, with policy compliance reported back through our Audit and Clinical Effectiveness Committee. Divisions are supported by the relevant teams in the roll out of and changes that have a bearing on day to day process. An example of this would be the support offered to infection prevention and control nurses who guide the roll-out of any changes to the way we work and ensure appropriate oversight of IPC related policies and procedures.
The policies are then placed on the Trust’s intranet which is accessible to all staff. This includes the potential to search on key words / phrases etc to identify relevant policies and procedures. There is also a direct link between the Trust’s policies and the Trust’s corporate induction and mandatory training. This ensures that staff are appropriately trained and briefed on current practices.
The Trust has recognised that further steps could be taken in evidencing that staff have accessed and read all policies which are critical to their role. To create this enhanced oversight, the Trust has plans to roll out a digital solution from Q4 2025/2026 called ‘Alertive’, which allows key critical messages to be issued to all staff with staff acknowledgements of these messages recorded. Whilst the first phase of the implementation will focus on operational processes within the Emergency Department, future phases will include the scoping of the cascade of policy documents to staff, which will begin from Q1 2026/2027.
I hope this response provides you with the assurance you are seeking that the Trust has taken this matter seriously and that plans are in place to resolve the concerns raised.
If you require any further information, please let me know.
Sent To
- Blackpool Teaching Hospitals NHS Foundation Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
31 Dec 2025
All responses received
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
Conclusion of Investigation (Section 4)
Narrative Conclusion. On 26th November 2020, Mrs Maureen Christy fell in the hallway of her home at 12 Toronto Avenue, Fleetwood, Lancashire, FY7 8HB. The cause of her fall was muscle wasting and consequential poor balance which was a natural expression of her frailty. Mrs Christy was transferred to Blackpool Victoria Hospital, and presented at the Accident and Emergency Department at 13.19 hours on the same date. An intracapsular fracture of the neck of the left femur was confirmed on plain x-rays. On 27th November 2020, Mrs Christy underwent a hemiarthroplasty under spinal analgesia. In the course of her admission, Mrs Christy presented with delirium, the causes of which were multifactorial. The delirium, low weight and cognitive impairment would have made Mrs Christy more vulnerable to Covid-19 and would have affected her ability to cope with it. On 8th December 2020 and/or shortly prior thereto, Mrs Christy was exposed to, and contracted, the SARS-CoV-2 virus on Bay 2 of Ward 35 of the Hospital, on which she was resident at the time. In consequence of the known exposure, she was identified as a “Covid contact” within the meaning of the Hospital’s internal guidance but was not tested for Covid-19 under the Hospital’s internal guidance at that time. The absence of such further testing in the Hospital did not contribute to Mrs Christy contracting the SARS-CoV-2 virus, or to her death. Mrs Christy was discharged home on 11th December 2020 and developed symptomatic Covid-19 on or around 14th to 16th December 2020, by reason of having been exposed to the SARS-CoV-2 virus in Bay 2 of Ward 35 of the Hospital, the Covid-19 being hospital-acquired. Mrs Christy’s presentation deteriorated and, on 4th January 2025 she died at home. Her death was verified at 00:15 hours on 5th January 2021. Frailty of old age had increased Mrs Christy’s vulnerability and was contributory to her death.
Cause of death:
1a Hospital-acquired Covid-19 infection b Hip fracture (operated) c
II Frailty of old age
Narrative Conclusion. On 26th November 2020, Mrs Maureen Christy fell in the hallway of her home at 12 Toronto Avenue, Fleetwood, Lancashire, FY7 8HB. The cause of her fall was muscle wasting and consequential poor balance which was a natural expression of her frailty. Mrs Christy was transferred to Blackpool Victoria Hospital, and presented at the Accident and Emergency Department at 13.19 hours on the same date. An intracapsular fracture of the neck of the left femur was confirmed on plain x-rays. On 27th November 2020, Mrs Christy underwent a hemiarthroplasty under spinal analgesia. In the course of her admission, Mrs Christy presented with delirium, the causes of which were multifactorial. The delirium, low weight and cognitive impairment would have made Mrs Christy more vulnerable to Covid-19 and would have affected her ability to cope with it. On 8th December 2020 and/or shortly prior thereto, Mrs Christy was exposed to, and contracted, the SARS-CoV-2 virus on Bay 2 of Ward 35 of the Hospital, on which she was resident at the time. In consequence of the known exposure, she was identified as a “Covid contact” within the meaning of the Hospital’s internal guidance but was not tested for Covid-19 under the Hospital’s internal guidance at that time. The absence of such further testing in the Hospital did not contribute to Mrs Christy contracting the SARS-CoV-2 virus, or to her death. Mrs Christy was discharged home on 11th December 2020 and developed symptomatic Covid-19 on or around 14th to 16th December 2020, by reason of having been exposed to the SARS-CoV-2 virus in Bay 2 of Ward 35 of the Hospital, the Covid-19 being hospital-acquired. Mrs Christy’s presentation deteriorated and, on 4th January 2025 she died at home. Her death was verified at 00:15 hours on 5th January 2021. Frailty of old age had increased Mrs Christy’s vulnerability and was contributory to her death.
Cause of death:
1a Hospital-acquired Covid-19 infection b Hip fracture (operated) c
II Frailty of old age
Circumstances of the Death
Box 3 of the Record of Inquest recorded as follows: See Box 4.
Copies Sent To
Mount View Practice
Lancashire County Council
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
GMC Code in Employment Contracts
Hyponatraemia Inquiry
Staff policy awareness
Staff training and development
Professional Codes in Employment Contracts
Hyponatraemia Inquiry
Staff policy awareness
Staff training and development
Clinical Guidance Dissemination Protocol
Hyponatraemia Inquiry
Staff policy awareness
Staff training and development
Fundamental standards of behaviour
Mid Staffs Inquiry
Staff policy awareness
Staff training and development
Standard Orders Prohibiting Five Techniques
Baha Mousa Inquiry
Staff policy awareness
Staff training and development
Ban Harsh Approach in Tactical Questioning
Baha Mousa Inquiry
Staff policy awareness
Staff training and development
Redefine trust-consultant contracts to specify resources and explicit work commitments
Bristol Heart Inquiry
Staff policy awareness
Staff training and development
Incorporate doctors' professional practice code into employment contracts and GP terms
Bristol Heart Inquiry
Staff policy awareness
Staff training and development
Incorporate professional codes of practice into contracts for nurses, allied professions, managers
Bristol Heart Inquiry
Staff policy awareness
Staff training and development
Prioritise non-clinical skills in healthcare professional education and development
Bristol Heart Inquiry
Staff policy awareness
Staff training and development
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.