Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0098, written 17 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 | 17 Feb 2026 |
|---|---|
| Reference | 2026-0098 |
| Deceased | Martin Ormond |
| Coroner | Alan Wilson |
| Coroner area | Blackpool & Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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: The Crescent Surgery Cleveleys Health Centre Kelso Avenue, Thornton Cleveleys, Lancashire FY5 3LF Broomwell HealthWatch Ltd TeleMedical Monitoring Services Barlow House (3rd Floor) 4 Minshull Street Manchester M1 3DZ 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 Martin Ormond on 25th January 2025 was reported to me and I opened an investigation, which concluded by way of an inquest on 13th February 2026. I determined the medical cause of death to be: 1 a Acute myocardial infarction 1 b Coronary artery atheroma 2 Bronchopneumonia, Essential hypertension, Type 2 Diabetes Mellitus In box 3 of the Record of Inquest I recorded as follows: Martin Ormond was aged 65 years. Concerned he may have a chest infection, he attended his GP surgery on the afternoon of 23rd January 2025. An ECG was performed but the risk he may suffer significant cardiac damage was not fully recognised and he was not advised to go to hospital. A cardiology referral was made which, it was envisaged, would lead to an outpatient appointment approximately two weeks later. After two days, on 25th January 2025, at 10.40 am, a request was made for an ambulance and it was reported that Martin had passed out but then during that call he appeared to recover, and by agreement the request for an ambulance was cancelled. That afternoon, further calls were made to the ambulance service during which concerns were raised about Martin’s fluctuating level of consciousness. At 1.26 pm an ambulance crew attended his home. An ECG was suggestive of a potential heart attack, but the urgency of the response indicated by that ECG was under-appreciated by the ambulance service personnel. Given the available evidence, a confusing situation ensued which culminated in the ambulance crew leaving the property on the understanding Martin and his Wife preferred to make their own way to hospital by way of their own transport, whilst Mrs Ormond felt she and Martin, buy not travelling to hospital in the ambulance, were acting on advice from the paramedics. Shortly after the paramedics left his home, and in the absence of cardiac monitoring, Martin’s condition deteriorated and a further call was made which led to a second ambulance crew attending. They arrived at his home some 27 minutes after the first crew had departed. They found Martin unresponsive and transferred him to hospital. Despite sustained CPR efforts from his family, paramedics and hospital personnel, he could not be revived and Martin died in the Emergency Department at 4.05 pm. A subsequent post mortem examination confirmed he died from the effects of an acute myocardial infarction. His death was more than minimally contributed to be pneumonia. 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: Two days before he died in hospital, Martin Ormond underwent an ECG (Electrocardiogram) at The Crescent Surgery on 23rd January 2025. At the inquest, evidence about this was provided by a Nurse Practitioner and a GP. The court heard that the Nurse Practitioner forwarded the ECG to an external company - Broomwell HealthWatch Ltd – who were to interpret the ECG. The ECG trace was considered, and a report sent to the Nurse Practitioner. Some nine minutes later, a further report was sent to the Nurse Practitioner which included some additional comments as follows: “Following further thought I would suggest this man is referred to A&E and hopefully angiography can be performed. ST elevation in a aVR and reciprocal ST depression elsewhere is suggestive of triple vessel disease and there is the risk that if the fast AF persists there may be a worsening of any O2/ perfusion mismatch resulting in worsening subendocardial ischaemia”. The evidence of the GP was that he had seen the ECG trace, but could not recall seeing either of the two subsequent reports provided by Broomwell HealthWatch. Neither did he recall being told verbally by the Nurse Practitioner that reference had been made to “triple vessel disease”, stating that had this been mentioned to him, he would have spoken to Mr Ormond and his Wife “to advise them he needed to be reviewed in hospital for further investigations, and that he needed to go to hospital within 24 hours”. The GP (who further to Mr Ormond’s death has now left the GP practice] and the Nurse Practitioner provided helpful evidence at the inquest, but it was lacking in clarity in some aspects, and I determined that the GP made decisions regarding Mr Ormond’s care at a time when he did not have the information he needed. It transpired that Mr Ormond was not advised to go to hospital at that time, but that a cardiology referral was made which meant he would most likely not be seen by a relevant medical professional for a period of around two weeks. It follows he had not seen a cardiologist by the time he died on 25th January 2025. The Nurse Practitioner informed the court that although Broomwell Healthwatch interpret many ECG traces for the GP surgery, he could not recall a previous occasion when a second report has been sent to the surgery in order to highlight some “additional comments”. When the second report was sent by email to the GP surgery, notwithstanding it was sent quickly, it seemed to me feasible that medical professionals may make decisions based on the first report, and that any important additional comments may go unnoticed, thereby placing patients at risk. 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 MATTERS OF CONCERN is as follows. – 1. At the GP surgery, a GP made decisions in the absence of the necessary information – notably two reports submitted by an external company asked to 2. interpret an ECG trace - and it did not seem that there was an effective process in place to ensure GPs are provided with the necessary information. In the event the external company decides to submit an amended report, there appeared to be no effective process in place to ensure what may be important additional information reaches the relevant GP before important decisions are made regarding patients. 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, but I have extended this period to 30th April 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 Martin Ormond North West Ambulance Service , GP. 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 18/02/26
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.
28th April 2026 To Mr Alan Anthony Wilson Senior Coroner for Blackpool & Fylde We have received your report regarding the death of Mr Martin Ormond. We would like to express our sincere condolences to the family of Mr Ormond. We have carefully considered your report. We have discussed the case with relevant persons within our service We do not know exactly what happened on the 23rd January 2025 but we think it likely that we would have made an assumption that; an email sent to the same email address as the original report, within a few minutes and marked as amended, would be read immediately whilst the patient was still there, and that sending an email would get the message through quicker than calling the surgery - as in our experience (with calling practices in general) waits to get through by telephone to GP practices are usually long. Having heard the evidence of the nurse at the hearing we see that such an assumption would not have been correct – as the nurse in this case said he did not see our second email. In the light of this evidence, we have recently instructed all relevant sta(cid:431) that; if an ECG shows significant abnormalities that may warrant an A&E admission and an amendment is made that adds to the urgency, then in such cases, in addition to sending an email, we should also always try to call the surgery to notify them. (Although as noted above, surgeries often do not answer calls in a timely manner.) This message has been communicated to all relevant sta(cid:431) on the 20th April 2026. We hope this addresses the concern raised to your satisfaction. Yours sincerely, Director of Broomwell Healthwatch
Hi , Thank you for your Regulation 28 Report to Prevent Future Deaths. The Practice has undertaken a detailed review of the circumstances surrounding this case and the processes identified. The clinicians involved with the practice management team have met to review both the statements provided and the contents of the Regulation 28 report in order to identify learning points and actions required to reduce the risk of recurrence. The issues raised have also been discussed with the wider practice team, including the sta(cid:431) responsible for performing ECGs, to ensure awareness of the concerns identified and to reinforce safe processes for the management and escalation of ECG results. In particular, we have highlighted concerns regarding amended or second ECG reports being issued up to 24 hours later without direct telephone contact from Broomwell Healthwatch to notify the Practice of significant changes to findings. We have also met with quality assurance colleagues from the Integrated Care Board (ICB), as Broomwell Healthwatch are commissioned to provide ECG services across Lancashire and South Cumbria ICB. During these discussions it was recognised that amendments to ECG reports may not be an isolated issue a(cid:431)ecting only The Crescent Surgery. This has not been confirmed but recognised that Broomwell Healthwatch supports a number of Practices across Lancashire and South Cumbria. As a result of this review, the Practice has updated its Standard Operating Procedure (SOP) to ensure that: Any amendments to ECG reports are recorded clearly within the patient’s medical records and reviewed by the On Call GP on the day they are received. Any amended urgent ECG reports are logged as a Significant Event and immediately flagged to the Practice Manager for internal review. Such incidents are also uploaded onto Ulysses, the ICB incident reporting system, to ensure commissioners are formally notified and wider system learning can take place. I have attached a copy of the updated Standard Operating Procedure (SOP) for your records. The Practice remains committed to learning from this incident and to strengthening governance and patient safety processes to help prevent future occurrences. Many Thanks Business Practice Manager The Crescent Surgery ( ) Cleveleys Health Centre Kelso Avenue Thornton-Cleveleys FY5 3LF Tel: Website Facebook
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