“It was the evidence of a number of clinicians who gave evidence in the course of the…”
Dated 27 Jun 2019, from the coroner for Blackpool and Fylde. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 22 Aug 2019. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated27 Jun 2019
- Deadline22 Aug 2019
- Published on judiciary.uk27 Jun 2019
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Blackpool Teaching Hospitals NHS Foundation TrustNamed in the report as “Blackpool Teaching Hospital” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 22 Aug 2019. A reply may have been sent and not yet published. |
| Glenroyd Medical Practice | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 22 Aug 2019. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) It was the evidence of a number of clinicians who gave evidence in the course of the inquest that they had not come across a death occasioned by epistaxis in the course of their clinical careers. In those circumstances the cause of the deceased’s death may have been unusual. In that regard he received oxygen therapy both in hospital and, following discharge, at home through a nasal cannula and was also prescribed Warfarin on account of his atrial fibrillation. Whilst, for much of the period in question his Internationalised Normalised Ratio fell within the target range of 2.0 — 3.0 he developed epistaxis which, in the context of and in combination with compromised lung and heart function due to pulmonary fibrosis and ischaemic heart disease, caused his death. In the course of preparing statements for the purpose of the inquest 2 practitioners did not identify and/or did not identify the significance of 2 references to nosebleeds (epistaxis) (or the possibility thereof) within the clinical records. Thus the concern arises that (1) the risks of epistaxis causing or contributing to death, particularly in a patient who is receiving oxygen therapy and/or who is taking Warfarin and/or who has underlying conditions which impair lung and/or heart function and (2) the fact that the risk of death may not be avoided merely on account of the maintenance of a patient’s Internationalised Normalised Ratio within a target range may not be known generally amongst clinicians such that circumstances creating a risk of other deaths will occur or will continue to exist in the future.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2019-0466
- Added to Minute Book
- 8 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
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