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 58%
Action Planned 32%
Noted 5%
Disputed 5%
Based on 19 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
65 results
Dorothy Imisson
Historic (No Identified Response)
2016-0496 5 Apr 2016
Blackpool Teaching Hospitals NHS Trust Care Quality Commission
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC guidance for record-keeping or NICE clinical guidelines.
Euphemia Aldred
Historic (No Identified Response)
2016-0062 18 Feb 2016
East Lancashire Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The provided concerns text is boilerplate and does not specify any particular safety issues or systemic failures regarding Euphemia Aldred's death.
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.
Sharon Henshall
Unknown
20 Aug 2015
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb immobilisation, coupled with varied national guidance, creates a 'postcode lottery' for prophylaxis.
Mary Hanson
Historic (No Identified Response)
2015-0148 21 Apr 2015
Lancashire Teaching Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Critical failures in the consent process included undocumented risk discussions, lack of patient information, and incomplete or improperly delegated capacity and best interests assessments by untrained staff.
Robbie Williamson
Historic (No Identified Response)
2015-0105 12 Mar 2015
Scotia Gas Network Wales and West Utilities Northern Gas Network +1 more
Child Death (from 2015) Other related deaths
Concerns summary Concerns exist regarding exposed, raised pipework, potentially attached to bridges, that is accessible to the public and may pose a safety risk.
David Ince
Historic (No Identified Response)
2014-0497 12 Nov 2014
North West Ambulance Service NHS Trust
Community health care and emergency services related deaths
Concerns summary Emergency ambulance staff frequently fail to routinely hand over patient ECG traces to A&E personnel, leading to critical information being missed during admission.
Dorothy Clarkson
Historic (No Identified Response)
2014-0465 26 Sep 2014
Care Quality Commission MPS Investments Ltd
Care Home Health related deaths
Concerns summary Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional development training for nursing home staff.
Kathleen Cornthwaite
Historic (No Identified Response)
2014-0333 18 Jul 2014
East Lancashire Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The concerns text provided for this report was incomplete, preventing a summary of specific issues.
Barry Dillion
Historic (No Identified Response)
2014-0099 5 Mar 2014
East Lancashire Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting patient care.
Mark Burgess
Historic (No Identified Response)
2014-0069 24 Feb 2014
Highways Agency
Road (Highways Safety) related deaths
Concerns summary The M65 motorway's decommissioned lighting system meant drivers could not see debris in the unlit carriageway, directly causing multiple subsequent collisions and injuries.
Muniza Mehrban
Historic (No Identified Response)
2013-0216 27 Aug 2013
Jesta Capital Corporation
Other related deaths
Concerns summary This marks the fourth death in three years at the multi-storey car park due to individuals jumping, indicating an urgent need for suicide prevention measures at the location.
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