“To: (i) Bloomfield Medical Centre (ii) Blackpool Teaching Hospitals NHS Foundation Trust…”
Dated 11 Jun 2023, from the coroner for Blackpool and Fylde. Sent to 4 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 6 Aug 2023. 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 dated11 Jun 2023
- Deadline6 Aug 2023
- Published on judiciary.uk13 Jun 2023
- Today28 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Bloomfield Medical Centre | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Aug 2023. A reply may have been sent and not yet published. |
| Blackpool Teaching Hospitals NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Aug 2023. A reply may have been sent and not yet published. |
| Lancashire & South Cumbria NHS Foundation TrustNamed in the report as “Lancashire and South Cumbria NHS Foundation Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Aug 2023. A reply may have been sent and not yet published. |
| North West Ambulance Service NHS TrustNamed in the report as “North West Ambulance Service.” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Aug 2023. A reply may have been sent and not yet published. |
The coroner’s concerns
A. To: (i) Bloomfield Medical Centre (ii) Blackpool Teaching Hospitals NHS Foundation Trust (iii) Lancashire and South Cumbria NHS Foundation Trust 1) There remains the potential for a lack of understanding amongst clinicians as to how urgent referrals into the PIMHT should be made. B. To: (i) Bloomfield Medical Centre (ii) Blackpool Teaching Hospitals NHS Foundation Trust (iii) Lancashire and South Cumbria NHS Foundation Trust (iv) North West Ambulance Service 2) There is inconsistent availability of access to mental health records across the service providers and information sharing between service providers using different data bases is difficult. C. To: (i) Blackpool Teaching Hospitals NHS Foundation Trust (ii) Lancashire and South Cumbria NHS Foundation Trust 3) There is a residual risk that reference to drug and/or alcohol misuse in mental health referrals and/or assessments may lead 2 to the missing of a mental health diagnosis and that circumstances may arise in which assumptions are made concerning substance misuse. D. To: (i) Bloomfield Medical Centre (ii) Blackpool Teaching Hospitals NHS Foundation Trust (iii) Lancashire and South Cumbria NHS Foundation Trust 4) There is a residual risk of non-communication of material information pertaining to patients’ mental health between healthcare providers. E. To: (i) Blackpool Teaching Hospitals NHS Foundation Trust (ii) Lancashire and South Cumbria NHS Foundation Trust 5) There is a risk that delayed assessment of patients who may appear to be or are reported to be intoxicated will give rise to a loss of opportunity to identify signs of psychosis.
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, 2023-0190
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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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