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 0%
Action Planned 100%
Noted 0%
Disputed 0%
Based on 1 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
Clear 19 results
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 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.
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.
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
Children’s Commissioner for England Department of Health and Social Care 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.
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.
Joan Rutter
Historic (No Identified Response)
2021-0066 8 Mar 2021
Riverside Rest Home
Care Home Health related deaths
Concerns 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.
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 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 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.
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 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
REDACTED
Other related deaths
Concerns 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.
Dennis Oldland
Historic (No Identified Response)
2017-0211 18 Sep 2017
Safehands Ltd
Community health care and emergency services related deaths
Concerns 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 Systemic failures included non-compliance with sepsis protocols, inadequate diabetic patient monitoring, issues with medication administration, and poor record-keeping, leading to fragmented and unreliable care.
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 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.
Freda Owens
Historic (No Identified Response)
2014-0559 27 Nov 2014
Lancashire Teaching Hospitals NHS Found… Croft House Rest Home Blackpool Teaching Hospital NHS Foundat…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about patient injuries, delayed specialist involvement, and suboptimal care.
Linda Lloyd
Historic (No Identified Response)
2014-0389 29 Aug 2014
Blackpool Teaching Hospital NHS Foundat…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Prior to review, concerns existed regarding triage being performed by non-senior nurses without adequate training, and departmental policy failing to consistently consider the effects of warfarin on patients.
Roy Frank Fletcher
Historic (No Identified Response)
2013-0362-wp24076 20 Dec 2013
Lancashire Care NHS Foundation Trust
Mental Health related deaths
Concerns summary The Trust's post-incident review was inadequate, failing to interview a key witness or assess if similar events were persistent issues, thus hindering learning and preventing future deaths.
Ethel Cross
Historic (No Identified Response)
2013-0362 5 Nov 2013
Blackpool Teaching Hospitals NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Wheeled chairs accessible to elderly patients caused falls, and a shortage of alarms for high-risk patients meant they could mobilize unsupported.