Marlene McCabe
PFD Report
Historic (No Identified Response)
Ref: 2023-0190
Coroner's Concerns (AI summary)
Systemic issues include a lack of clinician understanding for urgent mental health referrals, poor information sharing between providers, and a risk of misdiagnosis or delayed assessment due to assumptions about substance misuse.
View full coroner's concerns
A. To:
(i) Bloomfield Medical Centre (ii) Blackpool Teaching Hospitals NHS Foundation Trust (iii) Lancashire and South Cumbria NHS Foundation Trust
1) There remains the potential for a lack of understanding amongst clinicians as to how urgent referrals into the PIMHT should be made. B. To: (i) Bloomfield Medical Centre (ii) Blackpool Teaching Hospitals NHS Foundation Trust (iii) Lancashire and South Cumbria NHS Foundation Trust (iv) North West Ambulance Service
2) There is inconsistent availability of access to mental health records across the service providers and information sharing between service providers using different data bases is difficult. C. To: (i) Blackpool Teaching Hospitals NHS Foundation Trust (ii) Lancashire and South Cumbria NHS Foundation Trust
3) There is a residual risk that reference to drug and/or alcohol misuse in mental health referrals and/or assessments may lead to the missing of a mental health diagnosis and that circumstances may arise in which assumptions are made concerning substance misuse. D. To: (i) Bloomfield Medical Centre (ii) Blackpool Teaching Hospitals NHS Foundation Trust (iii) Lancashire and South Cumbria NHS Foundation Trust
4) There is a residual risk of non-communication of material information pertaining to patients’ mental health between healthcare providers. E. To: (i) Blackpool Teaching Hospitals NHS Foundation Trust (ii) Lancashire and South Cumbria NHS Foundation Trust
5) There is a risk that delayed assessment of patients who may appear to be or are reported to be intoxicated will give rise to a loss of opportunity to identify signs of psychosis.
(i) Bloomfield Medical Centre (ii) Blackpool Teaching Hospitals NHS Foundation Trust (iii) Lancashire and South Cumbria NHS Foundation Trust
1) There remains the potential for a lack of understanding amongst clinicians as to how urgent referrals into the PIMHT should be made. B. To: (i) Bloomfield Medical Centre (ii) Blackpool Teaching Hospitals NHS Foundation Trust (iii) Lancashire and South Cumbria NHS Foundation Trust (iv) North West Ambulance Service
2) There is inconsistent availability of access to mental health records across the service providers and information sharing between service providers using different data bases is difficult. C. To: (i) Blackpool Teaching Hospitals NHS Foundation Trust (ii) Lancashire and South Cumbria NHS Foundation Trust
3) There is a residual risk that reference to drug and/or alcohol misuse in mental health referrals and/or assessments may lead to the missing of a mental health diagnosis and that circumstances may arise in which assumptions are made concerning substance misuse. D. To: (i) Bloomfield Medical Centre (ii) Blackpool Teaching Hospitals NHS Foundation Trust (iii) Lancashire and South Cumbria NHS Foundation Trust
4) There is a residual risk of non-communication of material information pertaining to patients’ mental health between healthcare providers. E. To: (i) Blackpool Teaching Hospitals NHS Foundation Trust (ii) Lancashire and South Cumbria NHS Foundation Trust
5) There is a risk that delayed assessment of patients who may appear to be or are reported to be intoxicated will give rise to a loss of opportunity to identify signs of psychosis.
Sent To
Response Status
Linked responses
0 of 1
56-Day Deadline
6 Aug 2023
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
On 5 September 2019 an investigation was commenced into the death of Marlene McCabe. An inquest was opened on 10 September 2019. The investigation concluded at the end of the inquest held at Blackpool Town Hall on 6 March 2023 - 23 March 2023 and 3 May 2023.
Conclusion of Investigation (Section 4)
Unlawful killing. On 4th September 2019, between around 5.10pm and 5.50pm, Marlene McCabe was killed unlawfully in her own home. She died as a consequence of being struck a multiplicity of times to the head and face with a blunt object, namely, a doorstop, which occasioned catastrophic head and facial injuries. The actions of her assailant were more than minimally contributed to by the assailant's undiagnosed and untreated schizophrenia coupled with alcohol intoxication.
Cause of death:
1 (a) Severe blunt force head and facial injuries.
Conclusion of Investigation (Section 4)
Unlawful killing. On 4th September 2019, between around 5.10pm and 5.50pm, Marlene McCabe was killed unlawfully in her own home. She died as a consequence of being struck a multiplicity of times to the head and face with a blunt object, namely, a doorstop, which occasioned catastrophic head and facial injuries. The actions of her assailant were more than minimally contributed to by the assailant's undiagnosed and untreated schizophrenia coupled with alcohol intoxication.
Cause of death:
1 (a) Severe blunt force head and facial injuries.
Circumstances of the Death
Box 3 of the Record of Inquest recorded as follows:
On 4th September 2019, between around 5.10pm and 5.50pm, Marlene McCabe was killed unlawfully in her own home. She died as a consequence of being struck a multiplicity of times to the head and face with a blunt object, namely, a doorstop, which occasioned catastrophic head and facial injuries. The actions of her assailant were more than minimally contributed to by the assailant's undiagnosed and untreated schizophrenia coupled with alcohol intoxication. There were accepted prior failures in the collation and consideration of information, including from the available records and family, and in the mental health assessment of and progression of treatment for the assailant, in particular from early July 2019, which did not more than minimally contribute to Marlene McCabe's death.
On 4th September 2019, between around 5.10pm and 5.50pm, Marlene McCabe was killed unlawfully in her own home. She died as a consequence of being struck a multiplicity of times to the head and face with a blunt object, namely, a doorstop, which occasioned catastrophic head and facial injuries. The actions of her assailant were more than minimally contributed to by the assailant's undiagnosed and untreated schizophrenia coupled with alcohol intoxication. There were accepted prior failures in the collation and consideration of information, including from the available records and family, and in the mental health assessment of and progression of treatment for the assailant, in particular from early July 2019, which did not more than minimally contribute to Marlene McCabe's death.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Improve LAS procedures for timing and recording ambulance whereabouts
Fennell Inquiry
Ambulance Handover Delays
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.