“[250-word statement addressing what circumstances of the death have led to the coroner’s…”

The coroner’s concerns

[250-word statement addressing what circumstances of the death have led to the coroner’s concern, and why the coroner thinks the person to whom the report is directed is responsible for taking action to prevent future deaths. This statement must not propose what action should be taken, as coroners cannot make recommendations].   During the inquest I received evidence from a helpful witness who works at Blackpool Victoria Hospital as a cardiac coordinator who told the court that: –     She reviews referrals from local district hospital and facilitates the transfer of patients for coronary angiogram and other cardiac interventions that may be required. –    In her role, she finds herself dealing with transfers to Blackpool which ought to have happened earlier. I formed the view this could be for a range of reasons including – –    Limited personnel performing the cardiac coordinator role. –    No cardiac care-coordinator working over weekends and Bank Holidays. –    Poor record keeping. –    The number of cardiac patients the team in Blackpool deal with. –     A lack of understanding about the Acute Coronary Syndrome pathway and what is expected. My concern is the approach to some of the less obviously concerning cases – ACS pathway cases rather than PCI pathway cases – means patients who may need transfer to the regional cardiac centre are not being transferred in a timely manner therefore putting patients at risk. I forward this letter to you as the Chief Medical Officer so you can consider this concern with your senior colleagues in the cardiac centre. 11 COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles] 1. Furness General Hospitals Trust 2. The Chief Medical Officer at other district hospitals who may transfer patients to the regional cardiac centre, namely: Royal Preston Hospital Royal Lancaster Infirmary Chorley & South Ribble Hospital Royal Blackburn Teaching Hospital I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026;. Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE Roland Michaud – Prevention of future deaths report – 2026-0336_Published Download

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judiciary.uk, Prevention of Future Deaths reports, 2026-0336

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7 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0