Lancashire and Blackburn with Darwen

Coroner Area
Reports: 66 Earliest: Aug 2013 Latest: 31 Mar 2026

55% response rate (below 63% average).

Response Status
Responded 36 No Response 1 Historic 29
AI Classification
Action Taken 61%
Action Planned 26%
Noted 13%
Disputed 0%
Based on 46 classified responses
Top Categories
Hospital Death (Clinical Procedure… (34) Other related deaths (9) State Custody 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
66 results
David Aughton
Historic (No Identified Response)
2016-0183 12 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.
Sally Froggatt
Historic (No Identified Response)
2016-0481 11 May 2016
BMI Health Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was a failure to comply with the Duty of Candour, inadequate staff training, contradictory corporate guidelines, and nursing staff did not communicate known patient risk factors to consultants.
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 (AI 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 (AI summary) The report raises concerns that were not detailed in the excerpt.
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.
Sharon Henshall
Historic (No Identified Response)
20 Aug 2015
LTHTR LTHTR
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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 (AI summary) There was inadequate documentation of the risks and benefits of pituitary surgery discussed with the patient, missing information on capacity and best interest assessment forms, and a staff nurse may not have been the appropriate person to complete the proforma.
Robbie Williamson
Historic (No Identified Response)
2015-0105 12 Mar 2015
Association of Independent Gas Transpor… Northern Gas Network Scotia Gas Network +1 more
Child Death (from 2015) Other related deaths
Concerns summary (AI 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 (AI 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 Nesbit Law Group [Solicitors for the Cl…
Care Home Health related deaths
Concerns summary (AI 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 (AI 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 (AI 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 (AI 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 (AI 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.