Lancashire and Blackburn with Darwen
Coroner Area
Reports: 65
Earliest: Aug 2013
Latest: 9 Feb 2026
54% response rate (below 62% average).
Aaron Taylor
All Responded
2025-0566
6 Nov 2025
[REDACTED] HMP Garth
Suicide (from 2015)
Concerns summary
Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions for vulnerable prisoners were not consistently conducted, with staff unaware of required frequency.
Action taken summary
HMPPS ensures all new officers receive training on suicide and self-harm prevention, including ACCT processes. HMP Garth has issued staff notices and a Governor's order in October and November 2025 …
Adrienne Studholme
All Responded
2025-0504
10 Oct 2025
East Lancashire NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Inaccurate fluid balance charting, unrecorded seizure activity, and a lack of procedures for ED readmission after recent surgery, including insufficient triage training, posed significant risks.
Action taken summary
The Trust has clarified that seizure activity is escalated regardless of who witnesses it, communicating this to clinical teams. They have also reminded ED and surgical clinicians to ensure urgent …
Michelle Mason
All Responded
2025-0268
2 Jun 2025
NHS England
Lancashire Teaching Hospitals
Northern Care Alliance NHS Foundation T…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Lancashire lacks a 24/7 thrombectomy service and a clear plan for its delivery, compounded by non-stroke specialists' misunderstanding of service availability and a lack of regional mutual aid.
Action taken summary
Lancashire Teaching Hospitals has expanded its thrombectomy service to 7-day extended evening cover, updated its stakeholder communications policy and issued communications on service hours. They have
Sheila Edwards
All Responded
2025-0196
17 Apr 2025
Department for Transport
Road (Highways Safety) related deaths
Concerns summary
The driving licence system's reliance on self-reporting medical conditions, particularly dementia, is unsafe due to significant underreporting. This exposes other road users to substantial risk from drivers with compromised abilities.
Action taken summary
The Department for Transport acknowledges limitations in recording medical conditions in collision data and is keen to explore linking STATS19 data with DVLA driver records. It commits to continue wor
Peter Westwell, Mary Cunningham, Grace Foulds, Anne Ferguson
All Responded
2025-0197
17 Apr 2025
Department for Transport
Road (Highways Safety) related deaths
Concerns summary
The UK's driver licensing system has lax visual acuity checks, relying on flawed self-reporting over decades. This enables drivers with impaired vision to obtain licenses through deception, creating a significant road safety risk.
Action taken summary
The DVLA is considering why there has been a reduction in notifications for certain eye conditions, reviewing evidence from a 2023 call, and will consider inquest evidence to inform potential …
James Masheter
All Responded
2025-0167
3 Apr 2025
NHS Pathways
Alcohol, drug and medication related deaths
Emergency services related deaths (2019 onwards)
Mental Health related deaths
Concerns summary
The NHS Pathways system's limited mental health triage options inadequately assess serious mental health crises, leading to low priority categorisation and significant delays in ambulance response for at-risk patients.
Action taken summary
NHS England maintains that the NHS Pathways triage system elicited correct information for the patient in this case and is not considering further system changes for mental health triage at …
Ida Lock
All Responded
2025-0155
21 Mar 2025
University Hospitals of Morecambe Bay N…
NHS England
NHS Lancashire and South Cumbria Integr…
+1 more
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The Trust suffers from a deep-seated lack of candour, transparency, and deficient clinical governance, resulting in a failure to learn from past incidents, unreliable data, and inadequate reporting of serious harms.
Action taken summary
NHS England has launched the Maternity and Neonatal Safety Investigation Programme, established regional governance structures, and published a Three-year delivery plan for maternity and neonatal serv
Ava Hodgkinson
All Responded
2025-0016
10 Jan 2025
Department of Health and Social Care
Alcohol, drug and medication related deaths
Child Death (from 2015)
Concerns summary
Current pharmacy restrictions prevent pharmacists from issuing medication in a different strength, even if the correct dosage could be administered, causing dangerous delays in treatment.
Action taken summary
The DHSC is exploring new flexibilities for pharmacists to dispense alternative medication strengths without an amended prescription in cases of immediate clinical need. They plan to launch a formal p
Kevin Ince
All Responded
2024-0641
18 Nov 2024
Priory Group
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary
There was insufficient consideration and utilisation of legal powers under the Mental Health Act and Mental Capacity Act to ensure a detained patient received necessary treatment and nutrition.
Action taken summary
The Priory introduced flowcharts for managing declined physical health monitoring and poor diet/fluid intake, including capacity assessments and best interest meetings. A database to monitor food/flui
Marina Young
All Responded
2024-0527
4 Oct 2024
Lancashire Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
In A&E, prolonged patient stays lacked timely alerts to management, care needs were inadequately assessed for complex patients, and nurses lacked essential asthma assessment knowledge without senior escalation.
Action taken summary
The Trust has formulated an action plan to address all concerns regarding A&E capacity, patient flow, and care needs assessments. They commit to sharing further updates as these actions are …
Antony Waring
All Responded
2024-0399
17 May 2024
East Lancashire Hospitals Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A highly inappropriate surgical technique for suprapubic catheter insertion in a complex patient led to bowel perforation, compounded by inadequate use of imaging guidance and specialist consultation despite known risks.
Margaret Clement
All Responded
2024-0261
14 May 2024
East Lancashire Teaching Hospitals
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Inadequate nursing records and handovers, coupled with doctors' poor task prioritisation, resulted in failures to request timely medical reviews and urgent clinical assistance for a patient with a significant bleed.
Sarah Read
All Responded
2023-0460
17 Nov 2023
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
There is no provision for out-of-hours Thrombectomy Service after 5pm in Lancashire, and a lack of regional coordination means this urgent, lifesaving stroke treatment is unavailable when needed.
Harry Colledge
All Responded
2024-0096
16 Nov 2023
Lancashire County Council
Road (Highways Safety) related deaths
Concerns summary
Highway operatives lack specific training to identify road defects hazardous to cyclists. Additionally, a road's natural geological movement causes defects that current inspections may not adequately identify, posing risks to all road users.
Anthony Smith
All Responded
2023-0187
7 Jun 2023
HM Prison and Probation Service
State Custody related deaths
Concerns summary
The absence of protective mouth masks for resuscitation in prison exposes resuscitators to the risk of blood-borne viruses and could deter life-saving rescue breaths.
Daniel Nelson
All Responded
2022-0282
12 Sep 2022
Greater Manchester Mental Health NHS Fo…
Alcohol, drug and medication related deaths
Other related deaths
Concerns summary
The Trust lacked essential protocols, policies, or adequate standard operating procedures for governing Section 117 discharges, indicating a significant systemic gap in patient management.
Maziellie Mackenzie
All Responded
2022-0005
31 Dec 2021
Lancashire and South Cumbria NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary
The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient ratios, creating significant safety risks for patients.
Martin Brown
All Responded
2021-0417
15 Dec 2021
HMP Lancaster Farms
State Custody related deaths
Concerns summary
Prison staff lacked training for medical emergencies and the ERIC system. There was poor liaison between healthcare and ambulance services, and communication between emergency responders and the control room was inadequate.
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
The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis pathway activation and expediting critical scans.
Wesley Rowlands
All Responded
2020-0195
5 Oct 2020
HMP Garth
State Custody related deaths
Concerns summary
Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing risk.
Russell Curwen
All Responded
2023-0122
24 Apr 2020
Department for Transport
Other related deaths
Road (Highways Safety) related deaths
Concerns 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.
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
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.
Freda Mason
All Responded
2019-0126A
9 Apr 2019
Lancashire County Council
Road (Highways Safety) related deaths
Concerns 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.
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
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.
John Chapman
All Responded
2018-0007
11 Jan 2018
HMP Wymott
State Custody related deaths
Concerns 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.