Blackpool and Fylde

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

58% response rate (below 62% average).

Response Status
Responded 33 Historic 19 Pending 4
AI Classification
Action Taken 62%
Action Planned 38%
Noted 0%
Disputed 0%
Based on 8 classified responses
Top Categories
Hospital Death (Clinical Procedure… (32) Other related deaths (12) Care Home Health related deaths (8) Community health care and emergenc… (7) Child Death (from 2015) (5)
Quarterly Trend
Category Breakdown
How does this area compare?
vs North West average: -62 reports · -4pp response rate
vs national average: -26 reports · -4pp response rate
57 results
Mark Simpson
Response Pending
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 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.
Martin Ormond
Response Pending
2026-0098 17 Feb 2026
Broomwell Health Watch LYD Crescent Surgery
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Bonita Cleary
Response Pending
2026-0067 7 Feb 2026
Care Quality Commission Curo Care Delahey’s
Other related deaths
Concerns summary A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.
Janet Springall
Response Pending
2026-0074 7 Feb 2026
Care Quality Commission Department of Health and Social Care
Other related deaths
Concerns summary Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.
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 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 taken summary Blackpool Teaching Hospitals plans to roll out a digital solution called ‘Alertive’ from Q4 2025/2026 to improve the dissemination of critical messages and ensure staff acknowledgment of policies, wit
Keith Inseon
All Responded
2025-0243 27 May 2025
BARCHESTER HEALTHCARE LIMITED
Care Home Health related deaths
Concerns 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 summary Barchester Healthcare has reviewed its falls policy and processes, provided staff with further training on observation record keeping, and refreshed its digital care planning system to incorporate NEW
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 Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
Action taken summary Blackpool Teaching Hospitals NHS Foundation Trust has launched a Clinical Community to embed fluid balance work and developed a new, enhanced fluid balance chart for imminent rollout. They have also …
Imogen Heap
All Responded
2024-0620 8 Nov 2024
National Institute of Health and Care E…
Alcohol, drug and medication related deaths
Concerns 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 taken summary NICE will review evidence and consult with topic experts to consider updating guideline CG113 to make a specific recommendation on whether propranolol should be an option for generalised anxiety disor
Ryleigh Hillcoat-Bee
All Responded
2024-0371 12 Jul 2024
Department of Health and Social Care
Child Death (from 2015)
Concerns 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 taken summary DHSC refers to published UK Rare Diseases Framework action plans and ongoing Genomics Education Programme (GEP) initiatives to raise rare disease awareness. The GEP is developing a three-tier communic
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 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 summary Blackpool Teaching Hospitals reports significant improvements in sepsis management, with CQC licence conditions removed in July 2024, and maintains monthly updates to committees and a robust incident
Terence Manning
Partially Responded
2024-0495 10 May 2024
BLACKPOOL HADDON COURT REST HOME
Care Home Health related deaths
Concerns 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.
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 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.
Kirandip Bharaj
All Responded
2023-0379 9 Oct 2023
Blackpool Council
Other related deaths
Concerns summary Adult social care staff lack the tools, training, and guidance to recognise and act on concerning signs of eating disorders, risking unaddressed, urgent medical needs for vulnerable service users.
Sienna Monterio
Historic (No Identified Response)
2023-0344 16 Sep 2023
Royal College of Paediatrics and Child … Royal College of Obstetricians and Gyna… National Institution for Health and Car…
Child Death (from 2015)
Concerns 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 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.
Steven Duquemin
Historic (No Identified Response)
2023-0272 21 Jul 2023
Northern Care Limited
Other related deaths
Concerns 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 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.
Marlene McCabe
Historic (No Identified Response)
2023-0190 11 Jun 2023
Blackpool Teaching Hospitals NHS Founda… Bloomfield Medical Centre Lancashire and South Cumbria NHS Founda…
Other related deaths
Concerns 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
Department of Health and Social Care Children’s Commissioner for England Department for Education
Child Death (from 2015)
Concerns 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
Partially Responded
2022-0187 17 Jun 2022
Blackpool Teaching Hospitals NHS Founda… Lancashire and South Cumbria NHS Founda… Lancashire County Council +1 more
Care Home Health related deaths Mental Health related deaths Suicide (from 2015)
Concerns 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.
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 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.
Natalie Turner
All Responded
2022-0094 25 Mar 2022
Department of Health and Social Care British Association for Counselling and…
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 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.
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 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 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
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.