“Although it is not possible to say whether a CTPA procedure would have had an impact upon…”
Dated 22 May 2015, from the coroner for Blackpool and Fylde. Sent to 1 organisation or person.
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 17 Jul 2015. 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 dated22 May 2015
- Deadline17 Jul 2015
- Published on judiciary.uk22 May 2015
- Today28 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 NHS Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
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. Although it is not possible to say whether a CTPA procedure would have had an impact upon when Mrs Darbyshire died, | am concerned that two senior Doctors gave evidence that they were expecting an urgent CTPA to have taken place and that this had not happened some three days after the request was made. 2. lam concerned that according to the Radiology department there is no record of the clinical team responsible for Mrs Darbyshire’s care making efforts to “chase up” the missing CTPA procedure. 3. lam concerned that the radiology department staff have incorrectly categorised Mrs Darbyshire in a way that meant that she spent a number of days in hospital awaiting an urgent CTPA procedure that in reality was not going to happen because once categorised as an outpatient she realistically would only expect to receive a CTPA in 2015 by way of a written notification. 4. lamconcerned that given this request was made on 23 December 2014, subsequent events have been influenced by the fact that the request was made shortly before the Christmas period and that a lack of action taken by the clinical team to “chase up” the CTPA and the actions of the radiology department administration staff have been influenced by reduced staffing levels over the Christmas holiday period when the department would deal with inpatient requests only, and emergency requests pertaining to Accident & Emergency patients.
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
- 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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