Lancashire and Blackburn with Darwen
Coroner Area
Reports: 66
Earliest: Aug 2013
Latest: 31 Mar 2026
55% response rate (below 63% average).
Brody O’Brien
All Responded
2026-0084
9 Feb 2026
Health and Safety Executive
Rossendale Borough Council
Child Death (from 2015)
Concerns summary (AI summary)
An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely intervention.
Action Taken
(AI summary)
• HSE inspected the site in November 2025 and took enforcement action regarding improvements to site security.
• A further visit was made on 17th March 2026 to re-assess site security and the necessary improvements to the site fencing have been made.
• Liaison with legal and planning representatives from Rossendale Borough Council took place to share concerns and ensure that both organisations are working together. • A copy of the report was sent to the owner of Sunnyside Works, together with a s29 Local Government (Miscellaneous Provisions) Act 1982, requiring the building to be secured.
• The Council has been in communication with the owner of the Albert Mill site and they have confirmed that they are agreeable to taking access over their land to his property in order to carry out the securing of the building.
• The Council has been working alongside of the Health and Safety Executive and officers have spoken with him both over the telephone and in person on site.
John Alston
All Responded
2025-0616
NHS England
Care Home Health related deaths
Concerns summary (AI 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
(AI summary)
NHS Lancashire and South Cumbria ICB has changed and refined processes for sharing information when transferring patient funding to ensure all relevant details are shared with receiving ICBs. They now make clear to care providers when responsibility has transferred and hold weekly internal case progression meetings.
Aaron Taylor
All Responded
2025-0566
6 Nov 2025
[REDACTED] HMP Garth
Suicide (from 2015)
Concerns summary (AI 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
(AI summary)
HMP Garth issued a staff information notice promoting the Safety Learning Reference Library, and a Governor’s order reiterating ACCT processes. A priority keywork model is in place with a minimum of one keywork session per month for vulnerable prisoners.
Aaron Taylor
All Responded
2025-0565
6 Nov 2025
[REDACTED], Medical Director, Practice …
Suicide (from 2015)
Concerns summary (AI summary)
HMP Garth has a critical lack of psychologist resources for prisoners, with severe staffing gaps and extensive waiting lists for mental health support.
Action Planned
(AI summary)
Practice Plus Group is advertising for a Principal Psychologist, Clinical Assistant Psychologist and two Assistant Psychologists, and has interviewed candidates for the Principal Psychologist post. They are exploring sharing psychological resources with a neighboring prison in the interim.
Adrienne Studholme
All Responded
2025-0504
10 Oct 2025
East Lancashire NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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
(AI summary)
East Lancashire Hospitals NHS Trust has reinforced the importance of accurate fluid balance monitoring, updated triage protocols to include consideration of recent surgery, and clinicians have been reminded of the importance of escalating patient deterioration reported from any source.
Michelle Mason
All Responded
2025-0268
2 Jun 2025
Lancashire Teaching Hospitals
NHS England
Northern Care Alliance NHS Foundation T…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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 Planned
(AI summary)
Lancashire Teaching Hospitals has updated its stakeholder communications policy to reflect the current operational hours of the Mechanical Thrombectomy service and issued a follow-up communication for assurance through the Chief Operating Officers network. Direct contact has been made with Salford Royal Hospital to seek potential regional support options. Lancashire Teaching Hospitals has updated the stakeholder communications policy to reflect the current operational hours of the Mechanical Thrombectomy service and issued communications via Chief Operating Officers. NHS England is working with Lancashire & South Cumbria ICB to support Comprehensive Stroke Centres (CSCs) to deliver a 24/7 thrombectomy service. They have requested an urgent review of mechanical thrombectomy provision within the North West and expect a fully operational 24/7 service at the Preston site by October 2025. The Northern Care Alliance NHS Foundation Trust is participating in discussions with NHS England, Lancashire Teaching Hospitals and the Walton Centre to explore options for providing aid overnight, with follow-up meetings planned to progress plans and clarify timelines. A meeting between the Trust, NHSE and Lancashire Teaching Hospitals took place on 15 July 2025 to discuss this, where possible options for providing aid overnight were explored. Royal Lancaster Infirmary shared learning from the case and inquest feedback with the team, discussed it at a governance meeting, and is ensuring wider distribution of Royal Preston Hospital thrombectomy service hours, also added to handover sheets and nursing handovers.
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 (AI 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 Planned
(AI summary)
The Department for Transport details existing requirements for drivers to self-declare vision standards and medical conditions. The DVLA is considering research and evidence from a 2023 call for evidence, and will also consider evidence from the inquest to inform potential changes to driver licensing laws, as well as policy options as part of the Government’s Road Safety Strategy.
Sheila Edwards
All Responded
2025-0196
17 Apr 2025
Department for Transport
Road (Highways Safety) related deaths
Concerns summary (AI 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 Planned
(AI summary)
The Department for Transport acknowledges limitations in the STATS19 system for recording medical conditions in collision data and will explore linking collision data with DVLA records. The Department will also continue to work with healthcare professionals, driving organisations and regulatory bodies to enhance road safety.
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 (AI 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.
Noted
(AI summary)
NHS England acknowledges concerns about the use of NHS Pathways to triage mental health situations, notes it has already considered management of callers at risk of suicide, and will keep the clinical content under review. It also notes that the triage system elicited the correct information triggering the approved ambulance response.
Ida Lock
All Responded
2025-0155
21 Mar 2025
Department of Health and Social Care
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 (AI 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.
Noted
(AI summary)
NHS England discusses reports to prevent future deaths in a working group and escalates risks nationally through committees, referencing the Three year delivery plan for maternity and neonatal services and the Maternity and Neonatal Safety Improvement Programme. NHS Lancashire and South Cumbria ICB outlines measures in place to monitor compliance, including the reporting and escalation process and also that the North-West Regional Chief Midwife is developing Maternity Guidance and Principles with the aim to ensure there is a consistent approach in the identification and reporting of incidents. The Trust has reviewed practices, policies, and procedures, implemented mandatory training on candour, revised investigation processes, increased bereavement support, and implemented measures for consultant oversight. They also have enhanced incident review and executive oversight processes, including learning response leads. NHS Lancashire and South Cumbria ICB clarifies the independence and current availability of its Maternity and Neonatal Independent Senior Advocate role, noting it's under national evaluation and currently unable to accept new referrals.
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 (AI 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 Planned
(AI summary)
The DHSC is exploring new flexibilities regarding pharmacists supplying alternative doses and formulations, planning a formal public consultation on potential amendments to the Human Medicines Regulations 2012, with publication aimed for summer 2025.
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 (AI 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
(AI summary)
The Priory Group has introduced flowcharts at Kemple View for managing declined physical health monitoring and poor diet/fluid intake, including escalation procedures, capacity assessments, and best interest meetings; they have also created a database to monitor patients with food and fluid intake charts, reviewed weekly.
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 (AI 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 Planned
(AI summary)
Lancashire Teaching Hospitals NHS Trust has formulated an action plan to address the coroner's concerns and will share updates on its progress. The Trust met with the deceased's sister to offer apologies and involve her in overseeing improvements.
Antony Waring
All Responded
2024-0399
17 May 2024
East Lancashire Hospitals Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
The Trust has approved and ratified an SOP for 'Minimising the risks of supra-pubic catheter insertion in complex cases'. Weekly meetings led by the Clinical Director for Urology review theatre lists, and a pre-list check and brief is embedded within theatres. Clinical processes have been changed following evidence and research presented at the inquest.
Margaret Clement
All Responded
2024-0261
14 May 2024
East Lancashire Teaching Hospitals
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
The Trust has implemented changes including updates to nursing records, root cause analysis training, mandatory e-learning, SOP updates, and updated processes around monitoring of actions by adding assurance regarding completion of action plans to the PSG [Patient Safety Group] TOR (Terms of Reference) and agenda.
Sarah Read
All Responded
2023-0460
17 Nov 2023
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
Since September 2023, the Trust has increased thrombectomy service availability following a recruitment campaign. An investigation was undertaken and led to the formation of a Thrombectomy Operational Group and revision of governance structures.
Harry Colledge
All Responded
2024-0096
16 Nov 2023
Lancashire County Council
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
Lancashire County Council delivered debrief presentations to staff, undertook additional safety inspections, and implemented a temporary speed reduction. They commissioned a review of the Highway Safety Inspection Policy and a full Geotechnical Survey of Island Lane.
Anthony Smith
All Responded
2023-0187
7 Jun 2023
HM Prison and Probation Service
State Custody related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
The First Aid Policy Framework is being re-issued with instructions on face shield use, requiring all first aid kits to contain them and for them to be monitored. Face shields have been purchased and added to first aid boxes at HMP Preston, and staff were notified.
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 (AI 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.
Action Taken
(AI summary)
The Trust has developed a Section 117 Aftercare Policy, updated training for staff on Section 117 responsibilities, and updated their clinical record system to automatically flag patients eligible for aftercare. They will also hold a learning event on safe discharge and 117 responsibilities.
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 (AI 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.
Action Taken
(AI summary)
The Trust developed a written procedure regarding group leave from The Cove, approved it on 3 February 2022, and shared it with staff, suspending group leave until ratification. They also shared the procedure with other North West of England Tier 4 CAMHS providers.
Martin Brown
All Responded
2021-0417
15 Dec 2021
HMP Lancaster Farms
State Custody related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
Spectrum has developed an Emergency Response in Custody (ERIC) presentation and has been delivering training sessions to prison staff since January 2022. They have also implemented a system using a spare radio net for healthcare staff to communicate directly with the prison's communications room during medical emergencies, which went live on January 31st after a successful trial. The prison has distributed ERIC cards to all staff and commenced additional ERIC training delivered by the Head of Healthcare, with new staff receiving this training as part of their induction. A new radio channel process has been implemented for healthcare staff to communicate with the control room and ambulance service during emergencies.
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 (AI 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.
Action Planned
(AI summary)
Royal Blackburn Teaching Hospital has established a core group to oversee implementation of an action plan addressing concerns regarding detection of adverse outcomes, review of the case, and radiology practices, including improving communication, training, and referral processes, while also addressing factual inaccuracies in the case review.
Wesley Rowlands
All Responded
2020-0195
5 Oct 2020
HMP Garth
State Custody related deaths
Concerns summary (AI summary)
Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing risk.
Action Planned
(AI summary)
HMP Garth has arranged for the Prison Maintenance Group to review all cells and remove unused television brackets, with completion expected by February 2021. They are also reviewing accommodation in other prisons and alerting Prison Group Directors and Governors to the concerns.
Russell Curwen
All Responded
2023-0122
24 Apr 2020
Department for Transport
Other related deaths
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
The Department for Transport expresses sympathy and acknowledges the coroner's report. The response states the department is opposed to extending exemptions to road traffic laws and describes that existing laws and procedures did not appear to be followed in the incident.
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 (AI 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.
Action Planned
(AI summary)
Lancashire and South Cumbria NHS Foundation Trust is auditing documentation compliance weekly, monitoring Mental Health Act documentation daily, and has developed an inpatient safety matrix including Section 17 Leave. They are rolling out a pre and post leave assessment form and plan to undertake a rapid improvement event.