Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0561, written 4 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Nov 2025 |
|---|---|
| Reference | 2025-0561 |
| Deceased | Maureen Christy |
| Coroner | Tim Holloway |
| Coroner area | Blackpool & Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Blackpool Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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 Hospitals NHS Foundation Trust 1 CORONER I am Tim Holloway, Assistant Coroner, for the area of Blackpool & Fylde 2 CORONER’S LEGAL POWERS I 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) Narrative Conclusion. On 26th November 2020, Mrs Maureen Christy fell in the hallway of her home at 12 Toronto Avenue, Fleetwood, Lancashire, FY7 8HB. The cause of her fall was muscle wasting and consequential poor balance which was a natural expression of her frailty. Mrs Christy was transferred to Blackpool Victoria Hospital, and presented at the Accident and Emergency Department at 13.19 hours on the same date. An intracapsular fracture of the neck of the left femur was confirmed on plain x-rays. On 27th November 2020, Mrs Christy underwent a hemiarthroplasty under spinal analgesia. In the course of her admission, Mrs Christy presented with delirium, the causes of which were multifactorial. The delirium, low weight and cognitive impairment would have made Mrs Christy more vulnerable to Covid-19 and would have affected her ability to cope with it. On 8th December 2020 and/or shortly prior thereto, Mrs Christy was exposed to, and contracted, the SARS-CoV-2 virus on Bay 2 of Ward 35 of the Hospital, on which she was resident at the time. In consequence of the known exposure, she was identified as a “Covid contact” within the meaning of the Hospital’s internal guidance but was not tested for Covid-19 under the Hospital’s internal guidance at that time. The absence of such further testing in the Hospital did not contribute to Mrs Christy contracting the SARS-CoV-2 virus, or to her death. Mrs Christy was discharged home on 11th December 2020 and developed symptomatic Covid-19 on or around 14th to 16th December 2020, by reason of having been exposed to the SARS-CoV-2 virus in Bay 2 of Ward 35 of the Hospital, the Covid-19 being hospital-acquired. Mrs Christy’s presentation deteriorated and, on 4th January 2025 she died at home. Her death was verified at 00:15 hours on 5th January 2021. Frailty of old age had increased Mrs Christy’s vulnerability and was contributory to her death. Cause of death: 1a b c II Hospital-acquired Covid-19 infection Hip fracture (operated) Frailty of old age 4 CIRCUMSTANCES OF THE DEATH Box 3 of the Record of Inquest recorded as follows: 1 See Box 4. 5 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) The central policy or practice change with which this inquest was concerned was that pertaining to the testing of those designated as “Covid contacts”. (2) The adoption and understanding of good policy and practice, serves to protect patients and to provide clinicians with an overarching framework within which to work. It provides clinicians with the security of knowing what is expected of them in their clinical practice. (3) The policy change concerned was not acted upon in the case of the Deceased at the time of her being identified as a “Covid contact”. Notwithstanding the Trust’s recognition of the need to strengthen the dissemination of policy and practice changes, confusion around the dissemination of that policy or practice change, persisted to the time of evidence being given in this inquest. (4) Whereas steps are already being the dissemination of policy and practice changes, this investigation has revealed matters giving rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, by reason of shortcomings in the dissemination of policy and practice changes pertaining to clinical care. to address issue of taken the 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe Blackpool Teaching Hospitals NHS Foundation Trust has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 31st December 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, through their legal representatives were applicable: (1) (2) The Mount View Practice (3) Lancashire County Council son of Mrs Maureen Christy I 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. 2 9 Assistant Coroner for Blackpool & The Fylde (Signed electronically) Dated: 4th November 2025 3
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, 2nd Floor Blackpool Victoria Hospital Whinney Heys Road Blackpool, FY3 8NR 22 December 2025 Mr Tim Holloway Coroner for Blackpool and Fylde PO Box 1066 Corporation Street Blackpool, FY1 1GB Sent via email to: Dear Mr Holloway Re: Regulation 28: Report to Prevent Future Deaths – Maureen Christy Firstly, on behalf of Blackpool Teaching Hospitals NHS Foundation Trust, I would like to offer my sincere condolences to the family of Ms Maureen Christy. Thank you for raising your concerns with us and please find below the Trust’s responses to the issues raised in the report to prevent future deaths. 1. The central policy or practice change with which this inquest was concerned was that pertaining to the testing of those designated as “Covid contacts”. 2. The adoption and understanding of good policy and practice, serves to protect patients and to provide clinicians with an overarching framework within which to work. It provides clinicians with the security of knowing what is expected of them in their clinical practice. 3. The policy change concerned was not acted upon in the case of the Deceased at the time of her being identified as a “Covid contact”. Notwithstanding the Trust’s recognition of the need to strengthen the dissemination of policy and practice changes, confusion around the dissemination of that policy or practice change, persisted to the time of evidence being given in this inquest. 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. 4. Whereas steps are already being taken to address the issue of the dissemination of policy and practice changes, this investigation has revealed matters giving rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, by reason of shortcomings in the dissemination of policy and practice changes pertaining to clinical care. Thank you for the opportunity to respond to the concerns raised. The Trust would like to acknowledge the seriousness of the issues highlighted and wish to provide context regarding the challenges faced during the COVID-19 pandemic and the steps taken to mitigate risks. The COVID-19 pandemic presented unprecedented challenges for NHS hospitals. Guidance from national bodies evolved rapidly in response to emerging evidence and changing infection rates. This required hospitals to adapt operational practices at pace, often with very short implementation windows. Policies relating to infection prevention, patient care pathways, and staff safety were frequently updated, sometimes multiple times within a single week. The speed and frequency of changes created significant operational pressures. Key challenges included: • Volume and Complexity of Guidance: National directives were extensive and often required interpretation for local application. • Rapid Dissemination: Ensuring all staff were aware of and understood new requirements in real time was critical but difficult given shift patterns and workforce pressures. • Consistency of Practice: Maintaining uniform compliance across diverse clinical settings during periods of high demand was challenging. To address these challenges, the Trust implemented a structured approach to policy dissemination: • Central Coordination: A COVID-19 Response Group was established to review national guidance and translate it into local policy. • Digital Communication Channels: Updates were cascaded via email bulletins, intranet alerts, and a dedicated COVID-19 resource hub accessible to all staff. • Manager Briefings: Clinical and operational leads received daily briefings to ensure frontline teams were informed promptly. • Safety Huddles and Ward Meetings: Key changes were reinforced through regular huddles and team meetings to support understanding and compliance. • Training and Support: Where guidance required new clinical practices, rapid training sessions and e-learning modules were deployed. Response The Trust recognises the importance of learning from these experiences. Since the COVID pandemic, a number of refinements have been made to the Trust’s document control process, ensuring that these are reviewed, updated and approved within a robust process, and that new and updated documents are effectively communicated to staff. Overseen by the Trust’s Audit and Clinical Effectiveness Committee, the Trust ensures that it has in place documents which are in date and appropriately risk stratified in terms of the critical content. When a document is approved following drafting or review, these are communicated to staff by e-mail via the Trust’s Team Brief which is co-ordinated by the Trust’s Communications Department. All policies are ratified through an appropriate committee attended by representation from our clinical divisions, with policy compliance reported back through our Audit and Clinical Effectiveness Committee. Divisions are supported by the relevant teams in the roll out of and changes that have a bearing on day to day process. An example of this would be the support offered to infection prevention and control nurses who guide the roll-out of any changes to the way we work and ensure appropriate oversight of IPC related policies and procedures. The policies are then placed on the Trust’s intranet which is accessible to all staff. This includes the potential to search on key words / phrases etc to identify relevant policies and procedures. There is also a direct link between the Trust’s policies and the Trust’s corporate induction and mandatory training. This ensures that staff are appropriately trained and briefed on current practices. The Trust has recognised that further steps could be taken in evidencing that staff have accessed and read all policies which are critical to their role. To create this enhanced oversight, the Trust has plans to roll out a digital solution from Q4 2025/2026 called ‘Alertive’, which allows key critical messages to be issued to all staff with staff acknowledgements of these messages recorded. Whilst the first phase of the implementation will focus on operational processes within the Emergency Department, future phases will include the scoping of the cascade of policy documents to staff, which will begin from Q1 2026/2027. I hope this response provides you with the assurance you are seeking that the Trust has taken this matter seriously and that plans are in place to resolve the concerns raised. If you require any further information, please let me know. Yours sincerely Chief Medical Officer
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