Lancashire and Blackburn with Darwen
Coroner Area
Reports: 66
Earliest: Aug 2013
Latest: 31 Mar 2026
55% response rate (below 63% average).
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.
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.
Carl Hughes
All Responded
2015-0429
6 Nov 2015
Motor Cross Federation
Other related deaths
Concerns summary (AI summary)
Motorcross events do not mandate body protection for competitors, which could prevent fatal injuries.
Noted
(AI summary)
The response explains the MC Federation's role in motorsports event safety and states that they will not mandate the wearing of body protection at their events, arguing it's impractical and may displace participants to less regulated events.
Jacqueline Williams
All Responded
2015-0421-wp25020
2 Nov 2015
East Lancashire NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
• All staff were briefed on the referral process to ensure full understanding, and learning from the joint investigation was shared.
• The Trust met with East Lancashire Teaching Hospitals NHS Trust to explore in detail how to improve the referral process.
• The Trust is looking to utilise the CRISP board within the Emergency Department to record referrals made to specialist teams.
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 (AI 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.
Action Taken
(AI summary)
The Trust now uses 'EMIS web' to include a printed summary of the patient's GP record for urgent and emergency admissions (since April 2015). A consultant geriatrician is also piloting daily problem lists to document ongoing concerns during ward rounds.