Lancashire and Blackburn with Darwen
Coroner Area
Reports: 66
Earliest: Aug 2013
Latest: 31 Mar 2026
55% response rate (below 63% average).
Imre Thomas
Historic (No Identified Response)
2021-0097
4 Apr 2021
NHS England
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Cancelled hospital appointments put vulnerable prisoners at risk, highlighting a need to investigate organizing special prison clinics for hospital consultants.
Frank Medley
All Responded
2021-0057
2 Mar 2021
East Lancashire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis pathway activation and expediting critical scans.
Action Planned
(AI summary)
Royal Blackburn Teaching Hospital has established a core group to oversee implementation of an action plan addressing concerns regarding detection of adverse outcomes, review of the case, and radiology practices, including improving communication, training, and referral processes, while also addressing factual inaccuracies in the case review.
Gillian McKinlay
Historic (No Identified Response)
2021-0040
12 Feb 2021
Care Quality Commission
East Lancashire Hospitals NHS Trust
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There was no clear responsibility for A&E patients' overall care, and mandated clinical reviews for high EWS scores did not occur or were escalated. The Trust's serious incident investigation was inadequate, failing to address key issues or audit improvements.
Wesley Rowlands
All Responded
2020-0195
5 Oct 2020
HMP Garth
State Custody related deaths
Concerns summary (AI summary)
Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing risk.
Action Planned
(AI summary)
HMP Garth has arranged for the Prison Maintenance Group to review all cells and remove unused television brackets, with completion expected by February 2021. They are also reviewing accommodation in other prisons and alerting Prison Group Directors and Governors to the concerns.
Brett Marrs
Historic (No Identified Response)
2020-0179
23 Sep 2020
HMP Wymott
State Custody related deaths
Concerns summary (AI summary)
Prison officers lacked essential first-aid and resuscitation training, and welfare checks during cell unlocks were routinely neglected despite clear instructions, indicating systemic safety failures.
Russell Curwen
All Responded
2023-0122
24 Apr 2020
Department for Transport
Other related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The legal framework for "blood bike" volunteers' use of emergency vehicle exemptions (blue lights, speed limits) for routine courier services appears unclear, potentially leading to unsafe practices or misapplication of regulations.
Noted
(AI summary)
The Department for Transport expresses sympathy and acknowledges the coroner's report. The response states the department is opposed to extending exemptions to road traffic laws and describes that existing laws and procedures did not appear to be followed in the incident.
Andrew Jones
Historic (No Identified Response)
2020-0103
20 Apr 2020
National Offender Management
Alcohol, drug and medication related deaths
Mental Health related deaths
State Custody related deaths
Concerns summary (AI summary)
The prison service demonstrated a reduced capacity for self-harm risk assessment, with failures in re-evaluating risk after significant patient changes, providing adequate pain management, and informing new wings of altered risk profiles.
David Clark
All Responded
2020-0023
6 Feb 2020
Lancashire Care NHS Trust
Community health care and emergency services related deaths
Mental Health related deaths
Concerns summary (AI summary)
Deficiencies in documentation, failure to follow AWOL procedures, inadequate staff handovers, and a general lack of training on policy and procedure created significant safety risks.
Action Planned
(AI summary)
Lancashire and South Cumbria NHS Foundation Trust is auditing documentation compliance weekly, monitoring Mental Health Act documentation daily, and has developed an inpatient safety matrix including Section 17 Leave. They are rolling out a pre and post leave assessment form and plan to undertake a rapid improvement event.
Cherylee Shennan
Partially Responded
2019-0244
19 Jul 2019
HM Prison and Probation Service
Lancashire Constabulary
MOJ
Other related deaths
Concerns summary (AI summary)
Insufficient inter-agency communication and a lack of mandatory information sharing protocols for MAPPA Level 1 offenders with domestic abuse histories persist, despite known risks and previous reviews.
Action Taken
(AI summary)
Lancashire Constabulary is leading a multi-agency review of the MARAC process, testing new models for responding to cases in 'live-time', and is addressing the wider family impact of domestic abuse. They have also delivered DA and HBV/FMFGM training to probation officers and implemented 'Operation Encompass' with DA training to school staff.
Freda Mason
Partially Responded
2019-0126A
9 Apr 2019
Lancashire County Council
The Chief Coroner
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The council's reactive bus shelter maintenance system, relying only on public complaints, lacks a proactive inspection regime, leading to delays in identifying and repairing safety issues.
Action Planned
(AI summary)
The organisation will instruct staff visiting bus shelters to inspect and report damage, write to bus operators requesting they report damage, introduce a more prominent 'Report It' notice for the public, and write to district councils and advertising agencies to suggest they consider their own arrangements for reporting damage.
Margaret Clark
All Responded
2018-0050
10 Feb 2018
Medicines and Healthcare products Regul…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A change to new TOE probe sheaths (Ecolab) was linked to multiple fatal oesophageal tears, and these potentially unsafe sheaths may still be in use in other hospitals despite safer alternatives existing.
Noted
(AI summary)
The MHRA reviewed complaints and adverse incident databases regarding Ecolab sheaths and found few reports. They are unable to compare "softness" of sheaths and will continue to monitor the safety of TOE probe covers and take action if necessary.
John Chapman
All Responded
2018-0007
11 Jan 2018
HMP Wymott
State Custody related deaths
Concerns summary (AI summary)
A critical lack of formal procedures for sharing prisoner self-harm and welfare alerts between prison reception staff and healthcare nurses during medical screenings created a risk of significant alerts being missed.
Action Taken
(AI summary)
All reception staff at HMP Preston have been given a copy of PSI 07/2015 and made it an objective to read and comply; revised suicide and self-harm prevention training is being rolled out, prioritising reception staff; emergency boxes with resuscitation aids are on all residential units, and all staff with prisoner contact will be issued resuscitation aids by June; contingency plans have been amended to ensure staff are informed about the manner of all non-natural deaths. The prison and healthcare services have agreed that PER forms will be passed to the reception nurse as a matter of routine, who must then document within the SystemOne record that the form has been received and considered; they are exploring incorporating this check into the record system as part of the existing reception health screen template.
Kristina Cross
Historic (No Identified Response)
2018-0001
2 Jan 2018
Department for Health
Ministerial Correspondence and Public E…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Delayed surgical fixation of a traumatically fractured femur, caused by initial and subsequent misdiagnoses, led to post-operative complications and significantly contributed to the patient's death.
Christopher Talbot
Historic (No Identified Response)
2017-0427
29 Nov 2017
HMP Preston
HM Probation and Prison Service
Ministry of Justice
State Custody related deaths
Concerns summary (AI summary)
An untrained supervising officer relied solely on shadowing, a senior officer lacked a breathing guard for resuscitation, and staff were not informed of previous unnatural death causes, reducing vigilance.
Patrick Clifford
Historic (No Identified Response)
2017-0291
11 Oct 2017
East Lancashire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Lack of clear patient supervision policy in toilets, difficulties transferring radiology images between hospitals, and refusal to perform requested X-rays caused treatment delays.
Marcin Mazurek
Historic (No Identified Response)
2017-0282
7 Oct 2017
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Medical record keeping was of very poor quality, and daily or tri-weekly medical checks in segregation were often not recorded or did not occur.
Robert Cardwell
Historic (No Identified Response)
2017-0203
23 Jun 2017
Lancashire Care NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised meetings and poor record-keeping.
Michael Newell
Historic (No Identified Response)
2017-0123
13 Apr 2017
Lancashire Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Junior medical staff lacked awareness of liver failure's impact and early hypovolaemia, delaying critical treatment and consultant input. Inadequate nursing procedures and ineffective mortality reviews further compromised patient safety.
Stephen McDermott
Historic (No Identified Response)
2017-0071
17 Mar 2017
Lancashire Care Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Fragmented electronic record systems and poor record usage led to incomplete mental health assessments, missing critical patient history and suicide risk factors across different teams. Staff also lacked adequate training.
Alfred Grimshaw
All Responded
2016-0387
28 Oct 2016
East Lancashire Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A critical hip fracture was missed during initial assessment and an X-ray report. Pre-discharge physiotherapy and occupational therapy reviews were documented but not conducted, leading to discharge with unaddressed mobility issues.
Action Taken
(AI summary)
The Trust has strengthened communication processes for complex frail patient discharges, with emphasis on the Multidisciplinary Team and improved information transfer between primary and secondary care. The case has been used as a learning case for junior doctors.
David Wade
All Responded
2016-0324
6 Sep 2016
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The provided text is incomplete and does not detail specific concerns.
Noted
(AI summary)
NHS England highlights the existence and availability of the 'yellow book' which sets out symptoms requiring urgent medical advice for patients on anti-coagulant therapy. They emphasize the importance of not deterring patients from taking necessary anticoagulants.
Harry Gill
All Responded
2016-0323
30 Aug 2016
NHS Digital
Community health care and emergency services related deaths
Concerns summary (AI summary)
The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.
Action Taken
(AI summary)
NHS Pathways has amended the vomiting questions to be more specific, focusing on the nature of the vomit and the presence of coffee ground-like material. They have also enhanced the site training package for managing vomiting.
Andrew Peebles
Historic (No Identified Response)
2016-0484
13 Jun 2016
Lancashire Care NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Significant failures by RMNs included inadequate documentation of mental health assessments, insufficient review of critical patient information, and a lack of follow-up on referrals. Additionally, no internal investigation was conducted into the death.
Tracey Lynch
Historic (No Identified Response)
2016-0211
6 Jun 2016
Lancashire Care NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
Concerns summary (AI summary)
No specific concerns are provided in the truncated text.
Karen Ravenscroft
Historic (No Identified Response)
2016-0197
23 May 2016
East Lancashire Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The concerns text for this report is incomplete, so specific issues cannot be identified.