Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0074, written 7 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Feb 2026 |
|---|---|
| Reference | 2026-0074 |
| Deceased | Janet Springall |
| Coroner | Alan Anthony |
| Coroner area | Blackpool & Fylde |
| Category | Other related deaths |
| Organisation named | Blackpool Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Minister of State for Health [Secondary Care] Department of Health & Social Care C/O Ministerial Correspondence and Public Enquiries Unit Department of Health and Social Care 39 Victoria Street London SW1H 0EU Care Quality Commission By email – 1 CORONER I am Alan Anthony Wilson Senior Coroner for 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST The death of Janet Springall on 27th January 2025 was reported to me and I opened an investigation, which concluded by way of an inquest on 22nd January 2026. I determined that the medical cause of death was: 1a Sepsis 1b Pneumonia II Rheumatoid arthritis on immunosuppressant medication In box 3 of the Record of Inquest I recorded as follows: Janet Springall was aged 68 years. She had a learning disability and her medical history included previously diagnosed rheumatoid arthritis for which she was treated with immunosuppressant medication, placing her at increased risk of developing infection. After a period of six weeks in hospital, she was discharged to a care home on 10th January 2025 where she was visited regularly by her Sister. She could be reluctant to accept food and fluids. From approximately late afternoon on Thursday 23rd January 2025 she ate very little and ingested minimal fluids. On Sunday 26th January 2025 at shortly before 1.30 pm her Sister arrived to visit Janet and found her unresponsive but breathing. It is reported that a carer had seen Janet around fifteen minutes earlier, when Janet had rejected her medication but otherwise raised no concerns. From the available evidence, it cannot be stablished exactly when her condition began to deteriorate, but the deterioration had not been fully appreciated, thereby reducing the chances of Janet making a full recovery. An ambulance was requested and upon arrival, a paramedic found Janet unresponsive and hypoglycaemic. With medical assistance including intravenous glucose, she revived and was transferred to the local accident & emergency department where she was triaged at 16.58 hours that afternoon. Due to the very high number of patients in the department that day, many including Janet had to remain on ambulances. Over subsequent hours, her condition remained concerning and on occasions a paramedic sought to escalate her care with hospital staff but capacity pressures did not ease and it was not until 10.45 pm when she entered hospital. She was then reviewed by a doctor, a blood test performed and it was ascertained Janet was in septic shock and by 00.26 hours her condition was regarded as likely to prove non - survivable. Janet died at 00.42 hours on 27th January 2026. A post mortem examination confirmed Janet had pneumonia which had caused an overwhelming sepsis response and multi - organ failure which proved fatal. From the available evidence, by the time she arrived at hospital, Janet was very unwell and likely to die even if she had received a timely clinical assessment and necessary treatment including antibiotics. In the absence of such treatment, from approximately 7.30 pm that evening, any subsequent treatment would not have altered the outcome. In box 4 of the Record of Inquest I determined the conclusion to be one of: Natural causes 4 CIRCUMSTANCES OF THE DEATH In addition to the contents of section 3 above, the following is of note: Janet Springall had a learning disability, was immunosuppressed and at increased risk of infection, and due to pressures on the emergency department had to remain for many hours in the ambulance outside of the hospital. Paramedics, aware she was at serious risk of a life-threatening infection and required urgent treatment, raised their concerns but it was not possible to offload Janet from the ambulance for almost six hours after arrival. During the inquest, I was told as follows: In the past, in the event a patient had to remain on the ambulance outside hospital, it was possible for clinical / nursing staff to leave the hospital to provide some treatment on the ambulance; This no longer happens, and the court was informed this follows guidance from the Care Quality Commission [the CQC were not an Interested Person for this inquest] An experienced Clinical Matron provided helpful evidence to the court, and she explained how in terms of available resources, should nursing staff exit the hospital to conduct a blood test, for example, in an ambulance outside of the department this requires two members of staff to exit the emergency department which may leave often very unwell patients without urgent medical attention. In Janet’s case, an overwhelming sepsis response could not be confirmed until after midnight when blood test results were available. Had it been possible for hospital staff to access the ambulance to conduct a blood test earlier that day, once the results of that test were available, the administration of intravenous fluids and antibiotics may have mitigated the risk to her life. Janet was clearly very unwell upon arrival at hospital, and I found that by the time she entered hospital, it became clear she would die. I also found that by around 7.30 pm that evening, any subsequent treatment would not have altered the outcome. In the absence of urgent clinical assessment by hospital staff, the witnesses from the North West Ambulance Service, including the Paramedic who had been with Janet in the ambulance, explained how the focus of her care was on trying to ensure her condition remained stable and she did not deteriorate whilst before she could enter the department. Triage consisted of a discussion between the paramedic and the triage nurse inside of the department, and not in Janet’s presence, at shortly before 5 pm that day. It would have been clear to the triaging nurse that such were the exceptional pressures on the day it was likely Janet would be able to enter the department for many hours. An independent expert witness told the court how in his experience, there are circumstances in which the concerns for a patient are such that clinical staff will access the ambulance. This did not appear to be the position at hospital trusts in Blackpool. There is no doubt that on the day Janet went to hospital, the emergency department was experiencing exceptionally high patient numbers, and significantly higher than other similarly departments in the other hospitals in the region on that day. Blackpool Teaching Hospitals NHS Trust had conducted an internal review, and having considered that document, and having listened to evidence at the inquest, it appeared to me the Trust has made significant changes since Janet died with a view to minimising the number of patients who may have to wait on ambulances outside of hospital. This is to be welcomed. Having considered all of the above, I have determined that I have a duty to write this report. 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 could occur unless action is taken. In the circumstances it is my statutory duty to send the report: The MATTER OF CONCERN is as follows. – My concern is that notwithstanding the hospital Trust seems to have made welcome improvements, patients such as Janet Springall remain at risk. The Trust continues to experience significant pressures due to patient numbers, and unwell patients continue to remain in ambulances for some time before they are able to access the emergency department. When a very unwell patient has to remain on an ambulance due to very high demands placed upon a hospital emergency department, believed by paramedics to have a life- threatening infection, then in the absence of a blood test and the timely administration of any necessary intravenous fluids and antibiotics, the chances of such a patient surviving can be significantly reduced by the time the patient is able to access the emergency department. Janet Springall was very unwell by the time she arrived at hospital and was likely to die. Any realistic prospect she may recover had subsided by around 7.30pm, some 2.5 hours after arrival at hospital. Other patients may not be as unwell as Janet was upon arrival at hospital, and may therefore have more chance of surviving, but they too may deteriorate significantly whilst remaining in the ambulance before it can be confirmed they have an infection and receive timely medical attention and treatment. I believe it is necessary for to raise this concern, but it is not for me to be prescriptive about what should / can be done. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have 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. Given the approaching holiday period I have extended this period to 5TH April March 2026. I, the coroner, may extend the period further. 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: The family of Janet Springall North West Ambulance Service Blackpool Teaching Hospitals NHS Foundation Trust 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. 9 07/02/26 Signature Alan Anthony Wilson Senior Coroner Blackpool & Fylde
2 responses 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.
Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA HM Senior Coroner Alan Wilson HM Senior Coroner Blackpool & Fylde www.cqc.org.uk 22 April 2026 Care Quality Commission Dear HM Senior Coroner Wilson, Prevention of future death report following inquest into the death of Janet Springall Thank you for your Regulation 28 Report dated 7 February 2026 concerning the sad death of Janet Springall. We wish to express our condolences to Janet Springall’s family. Although the Care Quality Commission (CQC) was not an Interested Person at the inquest, your report records an assertion made verbally that: clinical staff had previously been able to attend patients in ambulances outside the hospital; and this no longer occurred because of guidance from the Care Quality Commission. Given that this assertion related directly to assumed CQC guidance, we considered it necessary to undertake a focused internal review to determine whether CQC had issued any instruction or advice that could have contributed to a change in practice. CQC have carefully considered whether CQC issued guidance relating to the treatment of patients on ambulances. Following receipt of the Regulation 28 report, CQC reviewed: Inspection documentation for the 3 inspections carried out at the trust between 2021 and 2022; Audio from relevant parts of the inquest where this assertion was mentioned; And our publications and guidance from 2021 onward CQC have also sought further information from the trust on the nature of the alleged guidance indicated during the inquest. The trust informed CQC that the comment was made verbally by a member of the trust staff, who said she believed it had been advice provided during one of the inspections conducted between 2021 and 2022. She recalled the advice being given in the context of an incident where a patient had come to harm and where nurse to patient ratios in the department were affected by a member of staff leaving the department to attend an ambulance. CQC have done a focussed review on the inspection reports, enforcement documentation and some inspection notes that would ordinarily capture such concerns or advice. There is no written record of any incident matching the description provided, nor any written evidence of CQC instructing or advising the trust that clinical staff should not treat patients on ambulances. Only one of the inspection leads involved remains employed by CQC, and although she has reviewed her notes, she does not recall giving such advice. CQC Position CQC has not issued any written guidance, instruction, or policy stating that clinical staff should not treat patients who remain on ambulances. Our published information and judgements in annual reports such as the State of Care acknowledge that ambulances are not the ideal environment for sustained care, but this is intended to highlight the risks associated with delays, not to prevent clinicians from treating patients when that is the safest immediate option. The 2021 State of Care report stated: “Ambulance handover delays are a consistent risk to the quality and safety of patients’ care. Although the care from ambulance crews during these waits tends to be good, ambulances are not the right locations to care for people once they have arrived at the emergency department.”. For clarity, CQC inspectors do not provide operational clinical advice to providers, including advice about how or where treatment should be delivered to specific patients. This is not within CQC remit, and inspection teams are trained to ensure that their role is to assess and report on the quality and safety of care, rather than to direct clinical practice. CQC recognises that informal conversations during inspections can sometimes lead to differing interpretations and CQC are committed to being as clear as possible about the limits of our role. However, CQC are unable to evidence that a conversation covering these issues took place during our inspection. From CQC’s review of the inspection findings across the 3 visits between 2021 and 2022, it is clear that CQC consistently raised concerns with the trust about ambulance handover delays and the number of people awaiting care in ambulances. In November 2025 CQC inspected the urgent and emergency care services at the trust. We did not find or escalate any concerns related to the quality and safety of ambulance handover processes during this inspection. Actions Taken and Ongoing Work Although CQC cannot evidence whether the guidance referenced during the inquest was or was not issued on-site by the inspection team, CQC recognise the seriousness of the risk identified in your report. CQC will: 1. Re-emphasise in our engagement with the trust the importance of safe clinical escalation processes for patients awaiting offload in ambulances, including clear policies on when clinical staff should attend patients outside the department. 2. Continue to monitor ambulance handover delays and their impact on patient safety at the trust through our ongoing regulatory activity, gathering evidence from the people who use services, frontline staff, NHS Ambulance services and system partners. 3. Provide refresher training for inspectors ensuring they are aware of our role and remit, and aware of the limitations on our remit which prevent our teams providing individualised guidance to providers. This guidance will also be made clear to providers during our inspections to ensure all parties understand CQC’s role and remit to assess and report on the quality and safety of care, rather than to direct clinical practice. CQC will continue to use its regulatory powers to ensure that the trust maintains effective systems to identify deteriorating patients, including those waiting outside the department, and manages risks within the emergency care pathway. Conclusion Our internal review has found no evidence; written or verbal within our records that CQC advised the trust not to treat patients on ambulances. CQC remain committed to encouraging care services to improve by working with the trust and system partners to ensure that patients receive safe and timely care, including during periods of sustained operational pressure. Please let us know if you require any further information. Yours sincerely, Deputy Director Network North- HSSC Care Quality Commission
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU HM Coroner Alan Anthony Wilson Blackpool & Fylde Coroner's Office, Municipal Buildings, Corporation Street, Blackpool, FY1 1GB 22 May 2026 Dear Mr Wilson, Thank you for the Regulation 28 report of 9th February 2026 sent to the Secretary of State / the Department of Health and Social Care about the death of Janet Springall. I am replying as the Minister with responsibility for Health. Firstly, I would like to say how saddened I was to read of the circumstances of Janet Springall’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over the continued pressure experienced in the emergency department in Blackpool Teaching Hospital NHS Trust causing patients to remain in ambulances despite needing immediate care within the department. In preparing this response, my officials have made enquiries with NHS England and Blackpool Teaching Hospital NHS Trust to ensure we adequately address your concerns. CQC have advised they will be providing a separate response to your concerns. DHSC and NHS England Actions NHS England and the Department of Health and Social Care recognise the ongoing pressures across urgent and emergency care, including ambulance services. To improve the quality and timeliness of patient care, the Department of Health and Social Care and NHS England published the 2025/26 Urgent and Emergency Care Plan (June 2025), the Medium Planning Framework 2026-27 to 2028/29 and the 10-Year Health Plan for England: Fit for the Future (July 2025). These set out key system priorities: reducing ambulance response times • • eliminating handover delays over 45 minutes and ending corridor care • improving hospital flow and discharge • expanding urgent care access across primary, community, and mental health settings Over £370 million in national capital funding supported these improvements. The plans also commit to shifting focus from treatment to prevention, reducing pressure on urgent and emergency care. To ensure timely patient care and release ambulances back into the community, the plan mandates the “Release to Rescue” approach. This requires the handover process to begin at 30 minutes and be completed by 45 minutes. NHS England continues to work with ICBs, acute trusts, and ambulance services to deliver the 45-minute maximum handover requirement, strengthen urgent community care, and improve hospital flow and discharge. Risks associated with long community waits for ambulances are regularly discussed at national forums to support shared understanding and coordinated action across the urgent and emergency care system. The Medium-Term Planning Framework (2026/27–2028/29) sets further ambitions for acute and ambulance collaboration, including progress toward the 15-minute handover standard. Local Actions Following the sad death of Ms Springall a Patient Safety Incident Investigation (PSII) involving North West Ambulance Service (NWAS) was conducted by Blackpool Teaching Hospitals NHS Trust (BTHT) under the Patient Safety Incident Framework. The investigation highlighted Ms Springall’s attendance at the emergency department via ambulance transfer during a period of extreme pressure with the Trust was operating at OPEL 4 and ambulance handover escalation protocols should have been activated. Investigation findings noted that although Ms Springall presented with significant risk factors, the triage assessment was inaccurate, did not acknowledge her recent admission, and did not consider sepsis despite Trust guidance requiring this on presentation. The report highlighted the following key findings: • Missed opportunities: Sepsis screening was not completed, escalation to a senior decision-maker (SDM) did not occur, and there was no clear patient ownership while she waited without a physical ED bed space. • Documentation gaps: The triage nurse’s retrospective statement lacked detail, and escalation actions were unclear. • Significant delays in assessment and treatment occurred. In response to the findings BTHT have: • Implemented the maximum ambulance handover time of 45 minutes, with a review to confirm embedding of policy scheduled for April 2026. • Additional training and education has been delivered to all ED nursing staff in recognising sepsis and the sepsis pathway. • The Trusts Learning Disabilities Team now regularly attends ED safety days highlighting the importance of obtaining history from families. • The ICB has overseen the implementation of a range of national and regional initiatives across Lancashire and South Cumbria Trusts with the aim to reduce the incidents of people being held outside EDs as a result of crowding with the departments and through the hospitals. The introduction of ‘Handover 45’ is a significant change from previous policy that outlined an escalation period at 8 hours. Work to reduce the current variation in compliance with Handover 45 is in place at site, trust, place and system, levels with oversight of progress via the UEC governance structures including Strategic Ambulance Improvement Group reporting into the Strategic System Improvement Group. There are UEC improvement plans in place across all Place and Trust teams that describe how local schemes relating to the improvement of flow lead to the delivery of the ICB’s UEC strategy. BTHT has been in Tier 1 for UEC since August 2025, requiring fortnightly reporting to NHS England on UEC performance improvements. As a result of being a Tier 1 site, they have benefitted from Getting It Right First Time UEC on-site clinical and operational improvement resource. In addition, the Regional Head of Learning Disability & Autism has confirmed that the ‘Learning from Lives and Deaths- people with a learning disability and autistic people’ (LeDeR) review for this case is underway and is focusing on learning around: • Journey prior to hospital admission – signs of deterioration, actions taken, support in the community • Reasonable adjustments / support while waiting (during conveyance to A&E and within A&E) I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
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