Lancashire and Blackburn with Darwen

Coroner Area
Reports: 65 Earliest: Aug 2013 Latest: 9 Feb 2026

54% response rate (below 62% average).

Response Status
Responded 35 Historic 28 Pending 1
AI Classification
Action Taken 65%
Action Planned 26%
Noted 4%
Disputed 4%
Based on 23 classified responses
Top Categories
Hospital Death (Clinical Procedure… (34) State Custody related deaths (8) Other related deaths (8) Mental Health related deaths (6) Road (Highways Safety) related dea… (6)
Quarterly Trend
Category Breakdown
How does this area compare?
vs North West average: -54 reports · -8pp response rate
vs national average: -18 reports · -8pp response rate
Clear 32 results
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 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.
David Wade
All Responded
2016-0324 6 Sep 2016
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The provided text is incomplete and does not detail specific concerns.
Harry Gill
All Responded
2016-0323 30 Aug 2016
NHS Digital
Community health care and emergency services related deaths
Concerns summary The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.
Carl Hughes
All Responded
2015-0429 6 Nov 2015
Motor Cross Federation
Other related deaths
Concerns summary Motorcross events do not mandate body protection for competitors, which could prevent fatal injuries.
Jacqueline Williams
All Responded
2015-0421 2 Nov 2015
East Lancashire NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The mental health referral system was prone to human error, failing to provide ED staff with confirmation of accepted referrals or assessment times. The Mental Health Liaison Team also lacked a process to identify patients awaiting assessment.
Jean Hannon
All Responded
2015-0458 30 Sep 2015
East Lancashire Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A critical diagnosis (autonomic dysreflexia) was not sufficiently highlighted in medical records, leading to a consultant's unawareness during a later admission and potentially inappropriate management.
John Alston
All Responded
2025-0616
NHS England
Care Home Health related deaths
Concerns summary Confusion and delays in identifying the correct Integrated Care Board (ICB) responsible for commissioning a patient's care led to delays in accessing appropriate support or placements.
Action taken summary NHS England reported that Greater Manchester ICB updated processes for out-of-area placements, developed a discharge protocol, and implemented specific training for commissioners. Lancashire and South