Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0318, written 17 Apr 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 Apr 2026 |
|---|---|
| Reference | 2026-0318 |
| Deceased | Julie Ley |
| Coroner | Robert Cohen |
| Coroner area | Cumbria |
| Organisation named | Lancashire & South Cumbria NHS Foundation Trust |
| Source | judiciary.uk record |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Miss K J Gomersal LLB | Senior Coroner | Cumbria
HM Coroner's Courts, Allerdale House, Workington, Cumbria CA14 3YJ
17 April 2026
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Lancashire and South Cumbria NHS Foundation
Trust
1) CORONER
I am Mr Robert Cohen, HM Assistant Coroner for Cumbria
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
On 19 May 2025 an investigation commenced into the death of Julie Ley. The investigation
concluded at the end of the inquest.
The conclusion of the inquest was the following narrative:
Julie Ley was 71 years old. She had a substantial history of mental illness. In December 2024
Mrs Ley's condition deteriorated and she became progressively more anxious and had
depressive symptoms. On several occasions Mrs Ley was admitted to hospital before being
discharged to different supportive environments. However on each occasion Mrs Ley's
symptoms made it impossible for her to care for herself and she was readmitted to hospital.
On 16th January 2025 Mrs Ley was admitted to the Kentmere Ward at Westmorland General
Hospital. Mrs Ley's condition worsened over time and she was detained under the Mental
Health Act 1983 from 7th April 2025.
The care received by Mrs Ley on the Kentmere Ward was inadequate. From mid April 2025
Mrs Ley became increasingly withdrawn and unkempt. Insufficient support was provided to
her. In May 2025 Mrs Ley stopped accepting medication, food or drink. Monitoring of Mrs
Ley's nutrition was not undertaken with appropriate diligence and she was not referred for
treatment at a more appropriate hospital where IV therapy could be administered. The
powers available under the Mental Health Act to give treatment without Mrs Ley's consent
were also not used.
Mrs Ley's physical condition deteriorated. Her risk of embolus was not properly monitored.
On 15th May 2025 Mrs Ley died, on the Kentmere Ward, as a result of a deep vein thrombi.
Her death was confirmed at 15:42.
Lancashire and South Cumbria NHS Foundation Trust have accepted that there were failures
in respect of Mrs Ley's nutrition, physical health monitoring, and use of legal frameworks and
that Mrs Ley would not have died but for these failings.
Mrs Ley's death was contributed to by neglect, being the failure to monitor her nutrition, the
failure to transfer her to a hospital able to treat her worsening condition and the failure to use
available powers to administer medication to her.
The medical cause of Mrs Ley's death was:
1a Myocardial fibrosis and pulmonary thrombo-emboli due to deep vein thrombi
1b
1c
II
4) CIRCUMSTANCES OF THE DEATH
In addition to the matters recorded in the above narrative, I heard evidence that when CPR
was delivered to Mrs Lay it took place on her bed, a soft surface.
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 consultant who was involved in performing CPR on Mrs Ley agreed that she had
been in bed at the time. When asked why he had not moved her to a solid surface he replied
that he had attended many advanced life support training sessions and had never been told
this was necessary. In their article "The impact of compliant surfaces on in-hospital chest
compressions: Effects of common mattresses and a backboard" in the journal Resucitation
(Vol 80, Issue 5, May 2009) the authors notes that carrying out CPR in a hospital bed may be
50% less effective. I am concerned that despite receiving training a senior clinician was
unaware of this and consider that it gives rise to a risk of future deaths.
6) ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you Lancashire
and South Cumbria NHS Foundation Trust 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,
namely by 12th June 2026. 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 Interested Persons
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.
17 April 2026
Signature
Robert Cohen
HM Assistant Coroner for Cumbria
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.
Lancashire & South Cumbria NHS Foundation Trust Sceptre Point Sceptre Way Walton Summit Preston PR5 6AW 24th April 2026 Private & Confidential Mr Robert Cohen His Majesty’s Assistant Coroner Sent by e-mail: Dear Mr Cohen Thank you for bringing your concerns to the Trust’s attention. We are grateful to you for identifying the matters set out in your report and for the opportunity to respond formally. On behalf of Lancashire & South Cumbria NHS Foundation Trust, I would also like to offer our sincere condolences to the family of Mrs Ley. We recognise the profound loss they have suffered and wish to reiterate our apology for the deficiencies in care identified within our internal investigation and during the course of the inquest. It is accepted that aspects of Mrs Ley’s care fell below the standard that she was entitled to expect, and we are deeply sorry for this. Your report highlights that cardiopulmonary resuscitation (CPR) was performed while Mrs Ley remained on a hospital bed, and refers to published literature from 2009 which indicates that chest compressions delivered on a compliant surface may be less effective than those delivered on a firm surface. You have expressed concern that this may give rise to a risk of future deaths. The Trust fully accepts the underlying principle that CPR is most effective when performed on a firm surface. However, the Trust considers it important to set out clearly the current national position, particularly as this response will be published and considered by a wider audience. Since the publication of the article cited in your report, national and international resuscitation guidance has evolved. Current Resuscitation Council UK guidance recognises that, although a firm surface is optimal, rescuers should not move a person from a soft surface, such as a bed, to the floor in order to commence CPR. The guidance emphasises that CPR should be started without delay on the bed and that, where required, chest compressions should be delivered with increased depth to compensate for mattress compliance, alongside the use of appropriate mitigation such as backboards. This guidance reflects the need to balance optimal CPR mechanics with the practical realities of in-hospital cardiac arrest, including the risks associated with manual handling and the importance of avoiding any delay in commencing life-saving treatment. The Trust’s resuscitation practice is aligned with this current national guidance. In response to the matters raised in your report, the Trust has nevertheless taken steps to reinforce and assure this position through resuscitation training, policy review, equipment assurance and clinical governance processes, in order to minimise the risk of misunderstanding or inconsistent practice in the future. The Trust confirms that it has no objection to this response being published and, indeed, considers publication to be important so that there is clarity regarding current resuscitation guidance and no misunderstanding about the Trust’s position in relation to CPR delivered in inpatient settings. We would, of course, be happy to meet with you or members of your office should you consider it helpful to discuss this response further or to provide any additional explanation. Thank you again for raising these matters. Yours sincerely, Chief Executive
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