Thomas Oldcorn
PFD Report
All Responded
Ref: 2025-0288
All 1 response received
· Deadline: 31 Jul 2025
Coroner's Concerns (AI summary)
Inadequate resources have led to significantly prolonged waiting times for cardiac surgery after angiography, consistently exceeding national targets and increasing to 17 days.
View full coroner's concerns
(1) T heard evidence during the course of Mr Oldcorn's inquest that despite National targets of 7 days from angiography to surgery at the time of his death the waiting time for surgery was 14 days that it has since risen to 17 days and that there are inadequate resources to_meet the national _target
Responses
Action Taken
The Trust has implemented daily reviews of the waiting list by the consultant body, with a clinical overview captured on a RAG-rated system. They are developing an escalation policy to ensure that any patient approaching the 7-day threshold is reviewed daily by a senior clinician and prioritised accordingly, with completion and ratification expected by September 2025. (AI summary)
The Trust has implemented daily reviews of the waiting list by the consultant body, with a clinical overview captured on a RAG-rated system. They are developing an escalation policy to ensure that any patient approaching the 7-day threshold is reviewed daily by a senior clinician and prioritised accordingly, with completion and ratification expected by September 2025. (AI summary)
View full response
Dear Ms Taylor
Re: Regulation 28: Report to Prevent Future Deaths
Thank you for your Regulation 28 Report dated 5th June 2025, concerning the delay in providing Coronary Artery Bypass Grafting (CABG) within the nationally recommended 7-day target. We acknowledge the seriousness of the concerns raised and extend our sincere condolences to the family of Mr Thomas Oldcorn.
We have undertaken a thorough internal review of the circumstances surrounding this case and the broader systemic issues that contributed to the delay. Our findings and actions are outlined below:
Background and Contributing Factors
At the time of the incident, our cardiothoracic service was experiencing capacity constraints due to theatre staffing shortages, list overruns and increased emergency demand leading to the on-call team being in during the night. The reasons for delays are summarised below:
Week Commencing No Surgeon No Anaesthetist List over run On-call team in during the night No CITU Bed Total Lost Cases 02/09/2024 2
2 09/09/2024
2 3 2
7 16/09/2024
3 2 2
7 23/09/2024 2 2
4 30/09/2024
Total 2 7 7 4 0 20
I would like to assure you that Mr Oldcorn was appropriately triaged and placed on the urgent surgical list. However, due to the above constraints, surgery was regrettably delayed beyond the 7-day national target. Mr Oldcorn’s wait for surgery exceeded this by 3 days meaning he would have waited 10 days from the time of being listed.
Actions Taken
We have implemented the following measures to address the identified issues:
Capacity Review
Whilst the service is planned to run on 50 weeks of the year, the job plans of both the Consultant Anaesthetists and Surgeons are based on 42 weeks so both flexible job sessions and cross covers are utilised in order to maintain the activity against plan. The Trust has recruited a Consultant Surgeon who commenced in post on 7th July 2025, and a Consultant Anaesthetist who is due to commence in post on 25th August 2025. Consultant annual leave policies at sub-speciality levels have been aligned to reduce the impact seen from lack of surgeon availability. In addition, the staffing levels across Theatres and Cardiac Intensive care have been authorised to recruit to the workforce gaps previously seen.
This approach helps the Trust from an operational perspective, with the aim to run 14 dedicated inpatient slots each week based on demand, with inpatients scheduled first on each list to support bed flow efficiencies. This capacity is flexible to accommodate any changes in demand or urgency of inpatient provision, and we also plan and run additional weekend inpatient lists, as permitted.
Real-Time Monitoring
A dashboard is in place to track all patients awaiting urgent CABG surgery, enabling proactive management and early identification of any potential delays. We have a dedicated nursing co-ordinator for inpatients who works closely with our dedicated Cardiothoracic Consultant Surgeon in-patient lead to regularly review each patient, monitoring their clinical priority and establishing a collective clinical overview. This review is captured on a RAG-rated system, with red/critical patients being given higher priority.
The above immediate action, implemented as a test of change, will now be formalised with the development of an escalation policy to ensure that any patient approaching the 7-day threshold is reviewed daily by a senior clinician and prioritised accordingly. The Trust will have the policy completed and ratified by September 2025.
Collaboration with Regional Networks
The Trust recognise that we are not achieving the 7-day national target. The first chart below shows our performance. This is a national issue, where the average waiting time is currently 14 days, which is a 4 day improvement since the last reported NACSA (National Adult Cardiac Surgery Audit), shown in the second chart below.
We are committed to continued improvement in this area and have strengthened our governance processes around monitoring and oversight to support this.
Ongoing Monitoring and Governance
Quality improvement methodology has been established to oversee compliance with national targets for urgent cardiac surgery.
Monthly audits are being conducted and monitoring of incidents and harms, with findings reported to the Trust Risk Committee, Clinical Governance Committee and Performance meetings with appropriate adjustments to the provision made.
Commitment to Improvement
We are committed to ensuring that no patient experiences avoidable delays in receiving time-critical cardiac surgery. The lessons learned from this case have been shared across the organisation, and we are determined to embed sustainable improvements.
We are grateful for the opportunity to respond to your report and will continue to monitor the effectiveness of our interventions.
Please do not hesitate to contact us should you require any further information.
Re: Regulation 28: Report to Prevent Future Deaths
Thank you for your Regulation 28 Report dated 5th June 2025, concerning the delay in providing Coronary Artery Bypass Grafting (CABG) within the nationally recommended 7-day target. We acknowledge the seriousness of the concerns raised and extend our sincere condolences to the family of Mr Thomas Oldcorn.
We have undertaken a thorough internal review of the circumstances surrounding this case and the broader systemic issues that contributed to the delay. Our findings and actions are outlined below:
Background and Contributing Factors
At the time of the incident, our cardiothoracic service was experiencing capacity constraints due to theatre staffing shortages, list overruns and increased emergency demand leading to the on-call team being in during the night. The reasons for delays are summarised below:
Week Commencing No Surgeon No Anaesthetist List over run On-call team in during the night No CITU Bed Total Lost Cases 02/09/2024 2
2 09/09/2024
2 3 2
7 16/09/2024
3 2 2
7 23/09/2024 2 2
4 30/09/2024
Total 2 7 7 4 0 20
I would like to assure you that Mr Oldcorn was appropriately triaged and placed on the urgent surgical list. However, due to the above constraints, surgery was regrettably delayed beyond the 7-day national target. Mr Oldcorn’s wait for surgery exceeded this by 3 days meaning he would have waited 10 days from the time of being listed.
Actions Taken
We have implemented the following measures to address the identified issues:
Capacity Review
Whilst the service is planned to run on 50 weeks of the year, the job plans of both the Consultant Anaesthetists and Surgeons are based on 42 weeks so both flexible job sessions and cross covers are utilised in order to maintain the activity against plan. The Trust has recruited a Consultant Surgeon who commenced in post on 7th July 2025, and a Consultant Anaesthetist who is due to commence in post on 25th August 2025. Consultant annual leave policies at sub-speciality levels have been aligned to reduce the impact seen from lack of surgeon availability. In addition, the staffing levels across Theatres and Cardiac Intensive care have been authorised to recruit to the workforce gaps previously seen.
This approach helps the Trust from an operational perspective, with the aim to run 14 dedicated inpatient slots each week based on demand, with inpatients scheduled first on each list to support bed flow efficiencies. This capacity is flexible to accommodate any changes in demand or urgency of inpatient provision, and we also plan and run additional weekend inpatient lists, as permitted.
Real-Time Monitoring
A dashboard is in place to track all patients awaiting urgent CABG surgery, enabling proactive management and early identification of any potential delays. We have a dedicated nursing co-ordinator for inpatients who works closely with our dedicated Cardiothoracic Consultant Surgeon in-patient lead to regularly review each patient, monitoring their clinical priority and establishing a collective clinical overview. This review is captured on a RAG-rated system, with red/critical patients being given higher priority.
The above immediate action, implemented as a test of change, will now be formalised with the development of an escalation policy to ensure that any patient approaching the 7-day threshold is reviewed daily by a senior clinician and prioritised accordingly. The Trust will have the policy completed and ratified by September 2025.
Collaboration with Regional Networks
The Trust recognise that we are not achieving the 7-day national target. The first chart below shows our performance. This is a national issue, where the average waiting time is currently 14 days, which is a 4 day improvement since the last reported NACSA (National Adult Cardiac Surgery Audit), shown in the second chart below.
We are committed to continued improvement in this area and have strengthened our governance processes around monitoring and oversight to support this.
Ongoing Monitoring and Governance
Quality improvement methodology has been established to oversee compliance with national targets for urgent cardiac surgery.
Monthly audits are being conducted and monitoring of incidents and harms, with findings reported to the Trust Risk Committee, Clinical Governance Committee and Performance meetings with appropriate adjustments to the provision made.
Commitment to Improvement
We are committed to ensuring that no patient experiences avoidable delays in receiving time-critical cardiac surgery. The lessons learned from this case have been shared across the organisation, and we are determined to embed sustainable improvements.
We are grateful for the opportunity to respond to your report and will continue to monitor the effectiveness of our interventions.
Please do not hesitate to contact us should you require any further information.
Sent To
- Blackpool Teaching Hospitals NHS Foundation Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
31 Jul 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) On 25 September 2024 commenced an investigation into the death of Thomas William OLDCORN: The investigation concluded at the end of the inquest_ The conclusion of the inquest was Thomas Oldcorn died as a consequence of a cardiac arrest at the Blackpool Victoria Hospital whilst awaiting delayed Cardiac MRI investigation and coronary artery bypass surgery: The inability to perform surgery within the national standard target contributed to his death: 1a Ischaemic Heart Disease 1b Atherosclerotic Stenosis of the left main Coronary 1c II Hypertension
Circumstances of the Death
Box 3 of the Record of Inquest recorded as follows: On 1 August 2024 Mr Oldcorn was admitted to Preston Hospital with shortness of breath and chest pains. An ECHO was performed and he was diagnosed with a non ST elevation myocardial infarction. He was transferred to the Blackpool Hospital on 4 September and underwent coronary angiography on 9 September. This revealed severe ostial left main stem disease He was referred for urgent in patient surgery: Requests were made for carotid doppler, vein mapping and pulmonary function tests_ On 10 September 2024 Mr Oldcorn was reviewed by the consultant cardiac surgeon. provisional date for surgery of 20 September was allocated which did not meet the national standard which recommends that in patients awaiting surgery are treated within days of angiography: On 12 September following a cardiac ward round a cardiac MRI was requested. The request was not marked as urgent: On 15 September Mr Oldcorn became tachycardic on 2 occasions. He experienced a further episode of non sustained ventricular tachycardia on 17 September: The cardiac MRI was chased by the cardiac coordinator who was informed that the radiology team were awaiting information about his pacemaker and the team's ability to be present during the scan: Patients are scanned on Tuesdayand Thursday mornings_The_next available slot was Artery
Thursday 19 September. At approximately 06.32 hours on 19 September Mr Oldcorn's heart rhythm on cardiac telemetry went into supraventricular tachycardia and then into ventricular tachycardia He became unresponsive CPR was commenced. Defibrillator pads were applied but his heart rhythm was documented to reflect pulseless electrical activity. A decision was made to cease resuscitation attempts Mr Oldcorn was pronounced deceased on 19 September at 07.34 hours_ On the balance of probabilities had it been possible to have operated upon Mr Oldcorn within the national standard target of 7 days he would not have suffered the cardiac arrest and died when he did:
Thursday 19 September. At approximately 06.32 hours on 19 September Mr Oldcorn's heart rhythm on cardiac telemetry went into supraventricular tachycardia and then into ventricular tachycardia He became unresponsive CPR was commenced. Defibrillator pads were applied but his heart rhythm was documented to reflect pulseless electrical activity. A decision was made to cease resuscitation attempts Mr Oldcorn was pronounced deceased on 19 September at 07.34 hours_ On the balance of probabilities had it been possible to have operated upon Mr Oldcorn within the national standard target of 7 days he would not have suffered the cardiac arrest and died when he did:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action,
Copies Sent To
Area Coroner for Blackpool & The Fylde Dated: 5 June 2025
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.