“That Blackpool Victoria Hospital has not yet finalised an agreement with Spire Fylde…”

The coroner’s concerns

– (1) That Blackpool Victoria Hospital has not yet finalised an agreement with Spire Fylde Coast Hospital for the urgent transfer of patients to the Ophthalmic Unit at Blackpool Victoria Hospital when appropriate. Unless arrangements are formalised, the lives of patients may be put at risk. 6 (2) That the Deceased was not seen by a speciality doctor in the Emergency Department notwithstanding the need for him to be seen. Unless action is taken there may be a continuing risk that patients in the Emergency Department will not be seen by on call doctors in speciality disciplines, in particular, ophthalmology, even when the need arises in that Department. (3)That the evidence disclosed omissions in the taking of vital signs observations and in the recording of observations in the vital signs observation chart (incorporating the National Early Warning Score). Unless action is taken, there is a risk that any deterioration in the condition of patients which might put their lives at risk will not be identified at the earliest opportunity. (4)That the evidence disclosed that the review process was not followed upon the Deceased’s blood pressure dropping by more than 40mmHg, notwithstanding the fact that that observation had been recorded. Unless action is taken, there is a risk that any deterioration in the condition of patients which might put their lives at risk will not be reviewed at the earliest opportunity. (5)That the evidence disclosed the fact that, whilst fluids had been prescribed, no prescription chart or fluid balance chart had been completed. Unless action is taken to ensure the completion of applicable documentation, the lives of patients may be put at risk. (6)That the evidence disclosed the fact that the Once-only and Pre-medication Chart does not make provision for the dose of medication actually given to be recorded in the event that the dose prescribed has been specified as falling within a range (for example, as here, morphine 1-10mg) and that, in any event, the actual dose given was not recorded in that chart. Unless the giving of medication is recorded fully the lives of patients may be put at risk.

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, 2020-0210

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

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