Blackpool and Fylde

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

61% response rate (below 63% average).

Response Status
Responded 35 No Response 2 Historic 20
AI Classification
Action Taken 65%
Action Planned 30%
Noted 2%
Disputed 2%
Based on 43 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: -63 reports · -2pp response rate
vs national average: -27 reports · -2pp response rate
Clear 34 results
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.
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.
Mark Hudson
All Responded
2014-0478 4 Nov 2014
Blackpool Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses that could harm patients.
Action Taken (AI summary) The Trust has undertaken training with senior members of the CICU Team, who are now competent in the placement of iGel tubes. A policy of using end tidal carbon monoxide monitoring for all intubated patients has been adopted. A review of the Out of Hours Anaesthetic Service was commissioned from the Royal College of Anaesthetists.
Linda Fisher
All Responded
2014-0226 9 May 2014
Blackpool Teaching Hospitals NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained or effectively communicated among staff.
Action Taken (AI summary) Blackpool Teaching Hospitals states that staff now perform a Mid Upper Arm Circumference calculation in line with the Malnutrition Universal Screening Tool (MUST) to assist is establishing an accurate weight, if it is not possible to weigh the patient.