Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0288, written 5 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jun 2025 |
|---|---|
| Reference | 2025-0288 |
| Deceased | Thomas Oldcorn |
| Coroner | Margaret Taylor |
| Coroner area | Blackpool and Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Blackpool Teaching Hospitals NHS Foundation Trust · Blackpool Teaching Hospital NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Blackpool Teaching Hospital NHS Foundation Trust 1 | CORONER lam Margaret Taylor, Area Coroner, for the area of Blackpool & Fylde 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST Conclusion of Investigation (Section 4) On 25 September 2024 | commenced an investigation into the death of Thomas William OLDCORN. The investigation concluded at the end of the inquest. The conclusion of the inquest was Thomas Oldcorn died as a consequence of a cardiac arrest at the Blackpool Victoria Hospital whilst awaiting delayed Cardiac MRI investigation and coronary artery bypass surgery. The inability to perform surgery within the national standard target contributed to his death. 1a ischaemic Heart Disease 1b Atherosclerotic Stenosis of the left main Coronary Artery 1c Il Hypertension 4 | CIRCUMSTANCES OF THE DEATH Box 3 of the Record of Inquest recorded as follows: On 1 August 2024 Mr Oldcorn was admitted to Preston Hospital with shortness of breath and chest pains. An ECHO was performed and he was diagnosed with a non ST elevation myocardial infarction. He was transferred to the Blackpool Hospital on 4 September and underwent coronary angiography on 9 September. This revealed severe ostial left main stem disease. He was referred for urgent in - patient surgery. Requests were made for carotid doppler, vein mapping and pulmonary function tests. On 10 September 2024 Mr Oldcorn was reviewed by the consultant cardiac surgeon. A provisional date for surgery of 20 September was allocated which did not meet the national standard which recommends that in - patients awaiting surgery are treated within 7 days of angiography. On 12 September following a cardiac ward round a cardiac MRI was requested. The request was not marked as urgent. On 15 September Mr Oldcorn became tachycardic on 2 occasions. He experienced a further episode of non - sustained ventricular tachycardia on 17 September. The cardiac MRI was chased by the cardiac coordinator who was informed that the radiology team were awaiting information about his pacemaker and the team's ability to be present during the scan. Patients are scanned on Tuesday and Thursday mornings. The next available slot was Thursday 19 September. At approximately 06.32 hours on 19 September Mr Oldcorn's heart rhythm on cardiac telemetry went into supraventricular tachycardia and then into ventricular tachycardia . He became unresponsive. CPR was commenced. Defibrillator pads were applied but his heart rhythm was documented to reflect pulseless electrical activity. A decision was made to cease resuscitation attempts. Mr Oldcorn was pronounced deceased on 19 September at 07.34 hours. On the balance of probabilities had it been possible to have operated upon Mr Oldcorn within the national standard target of 7 days he would not have suffered the cardiac arrest and died when he did. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (1) | heard evidence during the course of Mr Oldcorn's inquest that despite National targets of 7 days from angiography to surgery at the time of his death the waiting time for surgery was 14 days , that it has since risen to 17 days and that there are inadequate resources to meet the national target. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 31 July 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Thomas Oldcorn Blackpool Teaching Hospitals NHS Foundation Trust | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. (Por Margaret Taylor Area Coroner for Blackpool & The Fylde Dated: 5 June 2025
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Trust Headquarters
Blackpool Victoria Hospital
Whinney Heys Road
Blackpool
FY3 8NR
30th July 2025
Ms Margaret Taylor
Area Coroner – Blackpool & Fylde
Dear Ms Taylor
Re: Regulation 28: Report to Prevent Future Deaths
Thank you for your Regulation 28 Report dated 5th June 2025, concerning the delay in providing
Coronary Artery Bypass Grafting
target.
We acknowledge the seriousness of the concerns raised and extend our sincere condolences to the family
of Mr Thomas Oldcorn.
recommended 7-day
(CABG) within
the nationally
We have undertaken a thorough internal review of the circumstances surrounding this case and the broader
systemic issues that contributed to the delay. Our findings and actions are outlined below:
Background and Contributing Factors
At the time of the incident, our cardiothoracic service was experiencing capacity constraints due to theatre
staffing shortages, list overruns and increased emergency demand leading to the on-call team being in
during the night. The reasons for delays are summarised below:
Week
Commencing
No
Surgeon
No
Anaesthetist
List over
run
On-call team
in during the
night
No
CITU
Bed
Total Lost
Cases
02/09/2024
09/09/2024
16/09/2024
23/09/2024
30/09/2024
Total
2
2
2
3
2
7
2
3
2
7
2
2
4
2
7
7
4
0
20
I would like to assure you that Mr Oldcorn was appropriately triaged and placed on the urgent surgical list.
However, due to the above constraints, surgery was regrettably delayed beyond the 7-day national target.
Mr Oldcorn’s wait for surgery exceeded this by 3 days meaning he would have waited 10 days from the
time of being listed.
RESEARCH MATTERS AND SAVES LIVES – TODAY’S RESEARCH IS TOMORROW’S CARE
Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality
up to date care. We are actively involved in undertaking research to improve treatment of our patients.
A member of the healthcare team may discuss current clinical trials with you.
Actions Taken
We have implemented the following measures to address the identified issues:
Capacity Review
Whilst the service is planned to run on 50 weeks of the year, the job plans of both the Consultant
Anaesthetists and Surgeons are based on 42 weeks so both flexible job sessions and cross covers are
utilised in order to maintain the activity against plan. The Trust has recruited a Consultant Surgeon who
commenced in post on 7th July 2025, and a Consultant Anaesthetist who is due to commence in post on
25th August 2025. Consultant annual leave policies at sub-speciality levels have been aligned to reduce
the impact seen from lack of surgeon availability. In addition, the staffing levels across Theatres and
Cardiac Intensive care have been authorised to recruit to the workforce gaps previously seen.
This approach helps the Trust from an operational perspective, with the aim to run 14 dedicated inpatient
slots each week based on demand, with inpatients scheduled first on each list to support bed flow
efficiencies. This capacity is flexible to accommodate any changes in demand or urgency of inpatient
provision, and we also plan and run additional weekend inpatient lists, as permitted.
Real-Time Monitoring
A dashboard is in place to track all patients awaiting urgent CABG surgery, enabling proactive management
and early identification of any potential delays. We have a dedicated nursing co-ordinator for inpatients who
works closely with our dedicated Cardiothoracic Consultant Surgeon in-patient lead to regularly review each
patient, monitoring their clinical priority and establishing a collective clinical overview. This review is
captured on a RAG-rated system, with red/critical patients being given higher priority.
The above immediate action, implemented as a test of change, will now be formalised with the development
of an escalation policy to ensure that any patient approaching the 7-day threshold is reviewed daily by a
senior clinician and prioritised accordingly. The Trust will have the policy completed and ratified by
September 2025.
Collaboration with Regional Networks
The Trust recognise that we are not achieving the 7-day national target. The first chart below shows our
performance. This is a national issue, where the average waiting time is currently 14 days, which is a 4 day
improvement since the last reported NACSA (National Adult Cardiac Surgery Audit), shown in the second
chart below.
We are committed to continued improvement in this area and have strengthened our governance
processes around monitoring and oversight to support this.
Ongoing Monitoring and Governance
Quality improvement methodology has been established to oversee compliance with national targets for
urgent cardiac surgery.
Monthly audits are being conducted and monitoring of incidents and harms, with findings reported to the
Trust Risk Committee, Clinical Governance Committee and Performance meetings with appropriate
adjustments to the provision made.
Commitment to Improvement
We are committed to ensuring that no patient experiences avoidable delays in receiving time-critical cardiac
surgery. The lessons learned from this case have been shared across the organisation, and we are
determined to embed sustainable improvements.
We are grateful for the opportunity to respond to your report and will continue to monitor the effectiveness
of our interventions.
Please do not hesitate to contact us should you require any further information.
Yours sincerely
Acting Chief Executive Officer
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