Blackpool and Fylde

Coroner Area
Reports: 57 Earliest: Nov 2013 Latest: 11 Mar 2026

61% response rate (below 63% average).

57 results
Mark Simpson
All Responded
2026-0139 11 Mar 2026
Department of Health and Social Care Royal College of General Practitioners
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) NHS 111 reports to GP practices are not always reviewed by medically qualified staff, and critical information is often not added to patients' medical records, risking inappropriate clinical decisions.
Action Taken (AI summary) • The RCGP agreed that clinical correspondence, including reports from NHS 111, must be reviewed by a clinician before any decision is made about further action. • The RCGP's curriculum reflects the responsibility of GPs to respond to clinical correspondence in a timely manner to maintain safe patient pathways. • The RCGP supports CQC guidance that where non-clinical staff are involved in workflow tasks, there must be appropriate safeguards, supervision, training, and audit in place. • The GP practice has revised its workflow so that all clinical documents received from providers, including NHS 111 and out-of-hours services, are now reviewed by a clinician rather than administrative staff. • All incoming 111 and out-of-hours documents are attached to the patient record and sent as a clear task directly to a clinician as part of their daily workflow. • The GP practice now ensures that all consultation notes and reports are added to the patient’s medical record, coded and free-texted by the clinician.
Martin Ormond
All Responded
2026-0098 17 Feb 2026
Broomwell Health Watch LYD Crescent Surgery
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A GP made critical decisions without full information, and there was no effective process to ensure updated or additional reports reached the GP before patient management decisions.
Action Taken (AI summary) • The organisation has instructed all relevant staff that if an ECG shows significant abnormalities that may warrant an A&E admission and an amendment is made that adds to the urgency, then in such cases, in addition to sending an email, they should also always try to call the surgery to notify them. • This message has been communicated to all relevant staff on the 20th April 2026. • The Practice has updated its Standard Operating Procedure (SOP) to ensure that any amendments to ECG reports are recorded clearly within the patient’s medical records and reviewed by the On Call GP on the day they are received. • The Practice has updated its Standard Operating Procedure (SOP) to ensure that any amended urgent ECG reports are logged as a Significant Event and immediately flagged to the Practice Manager for internal review. • The Practice has updated its Standard Operating Procedure (SOP) to ensure that such incidents are also uploaded onto Ulysses, the ICB incident reporting system, to ensure commissioners are formally notified and wider system learning can take place.
Janet Springall
No Identified Response
2026-0074 7 Feb 2026
Care Quality Commission Department of Health and Social Care
Other related deaths
Concerns summary (AI summary) Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.
Bonita Cleary
No Identified Response
2026-0067 7 Feb 2026
Care Quality Commission Curo Care Delahey’s
Other related deaths
Concerns summary (AI summary) A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.
Maureen Christy
All Responded
2025-0561 4 Nov 2025
Blackpool Teaching Hospitals NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (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.
Action Planned (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.
Keith Inseon
All Responded
2025-0243 27 May 2025
BARCHESTER HEALTHCARE LIMITED
Care Home Health related deaths
Concerns summary (AI summary) Care home record-keeping was inaccurate and incomplete, as observation scores after a fall were not consistently recorded, hindering proper assessment for escalation to medical services. The system remains unaddressed.
Action Taken (AI summary) Barchester Healthcare has taken several actions including a review of training, refresher training on NEWS2, a new care planning digital system with guidance sheets, and themed supervision for staff. The falls policy has been reviewed and prompt sheets and guides have been created.
Brian Kneale
All Responded
2025-0043 23 Jan 2025
Blackpool Teaching Hospitals NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
Action Planned (AI summary) The Trust will update its Fluid Balance policy, roll out a new fluid balance chart with colour coding and other improvements, introduce mandatory afternoon checks, and update its Record Keeping Audit methodology to maintain direct oversight of fluid balance chart completion.
Imogen Heap
All Responded
2024-0620 8 Nov 2024
National Institute of Health and Care E…
Alcohol, drug and medication related deaths
Concerns summary (AI summary) There is a persistent under-appreciation of the severe risks posed by elevated Propranolol levels, a drug widely prescribed for anxiety, particularly in young people.
Action Planned (AI summary) NICE will review the evidence and consult with experts to consider updating guideline CG113 regarding recommendations on propranolol for the treatment of anxiety.
Sandra Phillpott
All Responded
2024-0372 12 Jul 2024
Blackpool Teaching Hospitals NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Despite prior concerns and reported improvements, there remains a persistent risk of sepsis going unrecognised and treatment being delayed at Blackpool Victoria Hospital.
Action Taken (AI summary) The Trust has implemented improvements to sepsis management, including training, audits, and pathway adjustments, and received a high assurance rating from the Mersey Internal Audit Agency, leading to the removal of Section 31 licence conditions.
Ryleigh Hillcoat-Bee
All Responded
2024-0371 12 Jul 2024
Department of Health and Social Care
Child Death (from 2015)
Concerns summary (AI summary) A critical lack of awareness among general paediatricians regarding rhabdomyolysis, a rare but serious condition in young children, risks missed diagnoses and fatal outcomes.
Action Planned (AI summary) The Department of Health and Social Care acknowledges concerns about rhabdomyolysis and LIPIN-1 deficiency. The GEP is utilizing frameworks and educator toolkits to deliver education and training and raise awareness of rare diseases to the wider workforce. The GEP will contribute by working with the Department and in collaboration with Medics for Rare Diseases (M4RD) on a number of solutions.
Terence Manning
All Responded
2024-0495 10 May 2024
HADDON COURT REST HOME, BLACKPOOL
Care Home Health related deaths
Concerns summary (AI summary) Inaccurate record-keeping, due to carers transposing details from other residents, led to incorrect dietary information for a resident, posing a risk to future patient safety.
Action Taken (AI summary) Haddon Court Rest Home has reminded staff about the importance of accurate record keeping and the risks of using the "repeat functionality" of their software; the software provider is reviewing the functionality.
Sabina Wood
All Responded
2024-0214 12 Apr 2024
Blackpool Teaching Hospital NHS Foundat… Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The practice of preparing speculative discharge summaries before patient readiness, coupled with IT system flaws and a lack of clear policy, risks inaccurate medical information being disseminated to GPs.
Action Taken (AI summary) The Trust is replacing its eDischarge system with a new integrated Nexus NPR platform which includes safeguards to prevent erroneous issuing of discharge summaries, requiring a password from the discharging clinician. The new system is being rolled out in phases, with full deployment expected by June 30, 2024, and a safety instruction regarding discharge summaries has been issued in the interim. DHSC notes that the medical director of Blackpool Teaching Hospitals NHS Foundation Trust has issued a letter to all medical staff regarding the population of discharge summaries with key messages to ensure discharge summaries are not prefilled. The trust also has an e-discharge project in place and ICB chief medical officers are asked to focus on and report their progress against recommendations on how to improve the interface between primary and secondary care.
Kirandip Bharaj
All Responded
2023-0379 9 Oct 2023
Blackpool Council
Other related deaths
Concerns summary (AI summary) The coroner notes that adult social care staff may lack the tools, training, and guidance to recognise and address eating disorders in vulnerable people, potentially leading to delays in necessary medical assessment and treatment.
Action Planned (AI summary) Blackpool Council is undertaking an internal review of the circumstances and will share the learning across services. They have a plan including AMHP supervision, exploring risk assessments and approaching LSCFT Eating Disorder service for an awareness session for all AMHPs early in 2024.
Sienna Monterio
Historic (No Identified Response)
2023-0344 16 Sep 2023
National Institution for Health and Car… Royal College of Obstetricians and Gyna… Royal College of Paediatrics and Child …
Child Death (from 2015)
Concerns summary (AI summary) A lack of national standardisation means blood gas analysers in neonatal resuscitation settings often fail to analyse haemoglobin levels, hindering critical decision-making and risking preventable infant deaths.
Harold Pedley
All Responded
2023-0316 1 Sep 2023
Department of Health and Social Care Lancashire and South Cumbria Integrated…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Emergency department pressures at OPEL 4 led to extensive triage delays and patient deaths, compounded by GPs not providing a realistic picture of waiting times.
Action Taken (AI summary) Lancashire and South Cumbria Integrated Care Board outlines actions taken by Blackpool Victoria Hospital, including revised communication protocols, staff training on triage and escalation, and direct GP referrals. They also detail how the ICB Primary Care Team is involved in communications with General Practices. DHSC acknowledges concerns about A&E wait times and refers to NHS England's 'Delivery plan for recovering urgent and emergency care services' which includes a target to improve A&E wait times. They cite dedicated funding to increase staffed hospital beds and improvements in performance at Blackpool Teaching Hospitals NHS Foundation Trust.
Steven Duquemin
Historic (No Identified Response)
2023-0272 21 Jul 2023
Northern Care Limited
Other related deaths
Concerns summary (AI summary) Inconsistent care records and a senior manager's under-appreciation of a vulnerable patient's choking risk led to inadequate preventative measures, endangering other service users.
Terence Burns
All Responded
2023-0243 14 Jul 2023
Highgrove Rest Home
Care Home Health related deaths
Concerns summary (AI summary) A patient's care plan failed to accurately document their essential blended diet, and critical nutritional information was not checked or transferred during hospital admission, risking appropriate care.
Action Taken (AI summary) Hospital passports are checked by two members of senior staff weekly, and Care Plans updated monthly or when any changes to care are required by a senior member of management. A hospital passport checklist has been implemented, and the provider contacted North West Ambulance Service to discuss the checklist.
Marlene McCabe
Historic (No Identified Response)
2023-0190 11 Jun 2023
Bloomfield Medical Centre, Blackpool Te…
Other related deaths
Concerns summary (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.
REDACTED
Historic (No Identified Response)
2023-0115 3 Apr 2023
Children’s Commissioner for England Department for Education Department of Health and Social Care
Child Death (from 2015)
Concerns summary (AI summary) Unacceptably long waiting times for young people's assessments due to finite resources placed children at risk, suggesting that earlier diagnosis and professional support could prevent deaths.
Margaret Stringer
All Responded
2022-0187 17 Jun 2022
Lancashire and South Cumbria NHS Founda…
Care Home Health related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) The care home lacked a documented system to restrict access to harmful items for at-risk residents and staff training on isolation's impact. Crucially, there were significant failures in transferring vital suicide risk information between agencies during patient handover.
Action Planned (AI summary) LCC will review the format of its overview document in line with the adoption of a strength based approach framework, which is planned to be rolled out across all Adult Social Care teams within the next 18 months. LCC have agreed to meet with and will continue to work with the Trusts in the future. BTHFT will collaborate with LSCFT and LCC to examine LSCFT's Admission, Discharge and Transfer of Care Policy and Procedure, to ensure that all relevant information, including suicide risk, is known, managed and communicated. A Joint Mental Health Governance Committee will meet quarterly to support the delivery and development of high quality care to patients with psychological and psychiatric needs. Nightingale's has implemented a new pre-admissions checklist covering relevant assessments, and will no longer admit residents with a similar history to Ms Stringer without 1:1 care. All staff receive training to facilitate communication with residents.
Sarah Dunn
All Responded
2022-0144 12 May 2022
Department of Health & Social Care
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths
Concerns summary (AI summary) Medical professionals lacked sufficient training and awareness regarding the rare but critical risk of sepsis following Early Medical Terminations, leading to significant delays in diagnosis and treatment.
Action Taken (AI summary) Blackpool Teaching Hospital Trust has ensured mandatory training on the risk of sepsis in Early Medical Terminations, introduced a sepsis educational programme, conducts monthly sepsis audits, and holds a monthly sepsis working group.
Natalie Turner
All Responded
2022-0094 25 Mar 2022
British Association for Counselling and… Department of Health and Social Care
Alcohol, drug and medication related deaths Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths
Concerns summary (AI summary) GPs lack specific guidance for managing complex eating disorders, especially when patients are unwilling to engage, leading to uncertainty in treatment. There is also a concern regarding counselling guidance when patients are unwilling to engage.
Action Planned (AI summary) BACP conducted a thorough review of member resources relating to confidentiality, competence, and eating disorders, detailed in an attached spreadsheet. The Department of Health and Social Care is working with NHS England and other bodies to improve eating disorder services, expand mental health services, and implement funding for transformed adult community mental health services by 2023/24.
Louise Cooper
Historic (No Identified Response)
2021-0431 21 Dec 2021
Department of Health and Social Care
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The healthcare system lacks sufficient provision for sustained supported eating for anorexia nervosa patients, leading to ineffective hospital admissions and hindering patient improvement despite clinical recommendations.
Marshall Metcalfe and Jane Ireland
Historic (No Identified Response)
2021-0406 25 Nov 2021
Department of Health & Social Care
Alcohol, drug and medication related deaths Child Death (from 2015) Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Other related deaths Suicide (from 2015)
Concerns summary (AI summary) Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge planning and continuity of care, which increases patient risk upon leaving the facility.
Barrie Housby
Historic (No Identified Response)
2021-0394 22 Nov 2021
Department of Health and Social Care Nottinghamshire County Council Sherwood Forest Hospitals NHS Foundatio…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Persistent and severe staffing shortages at the rehabilitation hospital compromised patient safety, making it impossible for staff to provide adequate care, particularly for vulnerable patients.