Blackpool and Fylde
Coroner Area
Reports: 57
Earliest: Nov 2013
Latest: 11 Mar 2026
61% response rate (below 63% average).
Coral O’Donnell
All Responded
2021-0152
Blackpool Teaching Hospitals NHS Founda…
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There was a lack of clinician awareness regarding PVL Staphylococcus Aureus and national guidance, compounded by poor communication between critical care and microbiology. Inadequate training on internal hospital systems also posed patient risks.
Action Taken
(AI summary)
Blackpool Victoria Hospital has implemented education and training sessions on PVL Staphylococcus Aureus, added a link to relevant guidelines on the Trust's intranet, and ensured all Critical Care Consultants received training on internal systems like Cyberlab. The CCG has discussed PVL-SA awareness at GP teleconferences, circulated information via its weekly bulletin to general practitioners, and noted that patient microbiology reports from Blackpool Teaching Hospitals now include a PVL-SA awareness message.
Joan Rutter
Historic (No Identified Response)
2021-0066
8 Mar 2021
Riverside Rest Home
Care Home Health related deaths
Concerns summary (AI summary)
Poor record-keeping, especially during night shifts, obscured important resident events. The delivery of overnight care meant staff were often unaware of residents needing assistance, posing risks.
Tina Murray
All Responded
2020-0296
22 Dec 2020
Belgravia Care Home Ltd
Care Home Health related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Plastic bags, which posed a risk to the deceased, appear to have been accessible within Belgravia Care Home.
Action Taken
(AI summary)
Belgravia Care Home removed plastic bags from resident bedrooms, safely disposed of shopping bags, locked away all other bags, and implemented robust risk assessments for residents at risk of suicidal tendencies.
Michelle Turner
All Responded
2020-0240
18 Nov 2020
Blackpool Clinical Commissioning Group
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Critical funding for peer support workers, who offer invaluable 'lived experience' and essential support for mental health and substance misuse, may be lost, jeopardizing vital services.
Action Planned
(AI summary)
The CCG has agreed to extend the current peer support worker provision until March 2022 and is transforming community mental health services as part of the Long-Term Plan, which includes peer support workers. The transformation model is due to be submitted to NHS England in January 2021.
Douglas Owens
All Responded
2020-0210
19 Oct 2020
Blackpool Teaching Hospitals NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Lack of formal transfer agreements and speciality doctor reviews in ED, coupled with widespread failures in vital signs observation, documentation, and medication recording, jeopardised patient safety.
Action Taken
(AI summary)
The Trust has developed a protocol for handover from Spire Fylde Coast Hospital to the Emergency Department and then ophthalmology and has reminded ED staff that variable doses of medication should be written on the PRN section of the chart. Morphine elixir has been treated as a restricted drug since November 2018, with all doses recorded in the restricted drugs register.
Isaac Newton
All Responded
2020-0174
14 Sep 2020
Department of Health and Social Care
Child Death (from 2015)
Other related deaths
Concerns summary (AI summary)
Despite guidance, young parents are continuing unsafe co-sleeping practices, often involving alcohol or drugs, and are not appreciating or following advice on safe sleeping environments, risking infant deaths.
Action Taken
(AI summary)
The Department of Health and Social Care detailed actions taken to raise awareness of co-sleeping risks, including releasing two short films with advice and incorporating safe sleeping advice into the Healthy Child Programme. Public Health England also plans to publish refreshed commissioning and delivery guidance for the Healthy Child Programme, including safer sleeping discussions and highlighting potential harms, in Q3 2020/21.
Dereck John Chapman
All Responded
2020-0165
27 Aug 2020
Rossendale Nursing Home
Care Home Health related deaths
Concerns summary (AI summary)
Nursing home staff provided an insufficient response to a high-fall-risk dementia patient, failing to account for his communication difficulties. Additionally, poor and unreliable record-keeping compromised accurate care narrative and incident review.
Action Taken
(AI summary)
Rossendale Nursing Home has implemented Person Centred Software, walk around handovers, pre-admission falls risk assessments, motion sensors, staff presence in communal areas, a post-fall protocol, referrals to the Falls team, CCTV, and monthly environmental audits to reduce falls risk.
Matthew Willoughby
All Responded
2020-0016
19 Jan 2020
Landlord
Other related deaths
Concerns summary (AI summary)
A landlord failed to ensure safety adaptions, such as window restrictors, remained in place after a tenant removed them, despite prior safety advice. This created a serious ongoing risk to tenants.
Action Taken
(AI summary)
The landlord confirms the adaptations to the windows in flat 10 have been replaced and all top floor flats windows have been checked for safety.
Matthews Rogers
Historic (No Identified Response)
2019-0448
20 Dec 2019
Blackpool Victoria Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Patient observations were not monitored hourly as required for a high NEWS score, likely due to nurse understaffing and high patient numbers, indicating an omission in care.
Frank Stockton
Historic (No Identified Response)
2019-0466
27 Jun 2019
Blackpool Teaching Hospital
Glenroyd Medical Practice
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Clinicians may lack awareness of the fatal risks of epistaxis, particularly in vulnerable patients on oxygen or Warfarin, and failed to recognize its significance in clinical records.
James Fletcher
All Responded
2019-0146
1 May 2019
Blackpool Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate guidance for caring for non-verbally communicative patients, poor record-keeping with missing entries and incomplete records, and significant miscommunication among medical and nursing staff compromised patient care.
Action Taken
(AI summary)
The Trust has implemented an Accessible Information Standard Policy, an Interpretation and Translation Procedure, and guidelines for the care of people with learning disabilities. It flags Blackpool residents with learning disabilities on electronic patient records and is working to extend this to Lancashire residents. A Red Alert has been issued to staff reminding them of vigilance for peritonitis in post-operative PEG tube patients.
Tina Tait
Historic (No Identified Response)
2019-0129
8 Apr 2019
Blackpool Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding crucial learning from deaths.
Christopher Bevan
Historic (No Identified Response)
2019-0104
20 Mar 2019
CORONER
Holloway Assistant Coroner for Blackpoo…
Iam Tim
Other related deaths
Concerns summary (AI summary)
Ladders were used unsafely on a slippery surface, unfooted, and improperly secured. This highlights a risk of unsafe work practices leading to falls and injury.
Adam Carter
All Responded
2018-0226
12 Jul 2018
Lancashire Care NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Poor record-keeping for a detained mental health patient meant risks, leave rationale, and assessments were undocumented, hindering informed decision-making and continuity of care for staff.
Action Planned
(AI summary)
Lancashire Care NHS Trust will prompt nursing teams to fully consider patient risks prior to leave, consider a minor amendment to the Leave Policy by 28 September 2018, pilot leave diaries in secure services, and the Clinical Director will write to consultants and ward managers about these actions by 14 September 2018. The impact of these actions will be included in a clinical audit in January 2019.
Sara Moran
All Responded
2018-0133
28 Apr 2018
Department of Health and Social Care
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for vulnerable service users.
Noted
(AI summary)
The Department of Health acknowledges concerns about capacity within mental health services, but emphasizes the responsibility of individual NHS Trusts for staffing levels and training. The response outlines existing CQC regulations, national guidance, and initiatives to improve access to psychological therapies and increase the mental health workforce.
Catherine Burns
All Responded
2018-0132
28 Apr 2018
Blackpool Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Emergency Department staff were overwhelmed by excessive patient numbers, leading to delays in doctor assessment and undetected patient deterioration, creating a risk of future deaths.
Action Planned
(AI summary)
The Trust is reviewing nursing and medical staffing in the Emergency Department, and has submitted a paper to the Executive Team for consideration of an increase in establishment. They are also embedding the Safer Care Bundle and are using Improved Streaming to the Urgent Care Centre and fast initial assessment.
Keith Harwood
All Responded
2018-0017
16 Jan 2018
Blackpool Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Medical professionals struggle to access urgent specialist advice for unfamiliar conditions despite Trust policies, potentially delaying appropriate care and requiring families to educate staff.
Action Planned
(AI summary)
The Trust will issue an internal alert reminding staff of the importance of timely management of patients with Parkinson's disease and timely referral to the Parkinson's Specialist Team and the availability of the procedure document on the Trust intranet.
Bernard Cosgrove
All Responded
2017-0285
10 Oct 2017
Blackpool Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital staff failed to recognise a patient's dislocated hip for 7 days, despite clinical record entries and physical handling. This highlights insufficient patient monitoring and inadequate consideration of previous medical records before discharge.
Action Taken
(AI summary)
The Trust has implemented an electronic patient record system where critical activities are flagged until actioned. Staff are receiving ongoing professional development, ward-based education, and reminders about their responsibilities.
Dennis Oldland
Historic (No Identified Response)
2017-0211
18 Sep 2017
Safehands Ltd
Community health care and emergency services related deaths
Concerns summary (AI summary)
Care workers prematurely leaving visits based solely on task completion and apparent contentment risks overlooking potential welfare concerns due to insufficient interaction time with vulnerable service users.
Barry Thompson
Historic (No Identified Response)
2016-0354
11 Oct 2016
Blackpool Teaching Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The patient's high-priority triage was not followed by timely review by a doctor or antibiotic administration per national standards, the NEWS score was not actioned, and there were issues managing a diabetic patient's monitoring and basic needs, along with inaccurate and incomplete record-keeping.
Jane Bell
All Responded
2016-0119
22 Mar 2016
Dalmeny Hotal
Other related deaths
Concerns summary (AI summary)
Insufficient poolside supervision at the hotel due to infrequent patrols and reliance on CCTV monitored by reception staff who are also busy with other tasks, creating a risk of future deaths.
Action Taken
(AI summary)
The hotel has implemented constant poolside supervision, including patrolling staff and CCTV monitoring, with head counts recorded every 30 minutes. They have also hired a leisure club manager with extensive qualifications.
Piotr Kucharz
All Responded
2015-0465
24 Nov 2015
Lancashire Care NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Mental health staff displayed a critical lack of consistency and clarity on what constitutes an effective patient observation, with some failing to enter rooms or engage. This systemic ambiguity puts vulnerable patients at risk due to inadequate monitoring.
Action Planned
(AI summary)
The Trust is planning an external review of its new clinical risk assessment tool and policy in April 2016. A revised observation policy and procedure will be implemented by 31 March 2016, and an internal patient safety alert has been issued to remind staff of the current policy.
Jean Gillespie
All Responded
2015-0419
2 Nov 2015
Alexandra Court Care Home
Care Home Health related deaths
Concerns summary (AI summary)
Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home records also lacked critical information about the condition.
Action Taken
(AI summary)
Senior Care Assistants received further medication training and competency assessments, including a supervision after the inquest. The new manager introduced handover and medication count down sheets for improved communication and stock control.
Dennis Stark
Historic (No Identified Response)
2015-0420
30 Oct 2015
Newton House (formerly Regency Hospital)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A rehabilitation unit's lack of a lift significantly delayed the emergency removal of an obese patient from a second-floor room, posing a risk of future deaths for individuals requiring urgent medical attention.
Olive Darbyshire
Historic (No Identified Response)
22 May 2015
Blackpool Teaching Hospital NHS Foundat…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
An urgent CTPA procedure was delayed and miscategorised, exacerbated by a lack of follow-up from the clinical team, radiology department errors, and potential impact of reduced Christmas staffing levels.