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22/08/2025
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22/10/2025
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LOWRY, James Terence
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Died from cardiac myopathy contributed to by multiple drug use
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29/08/2025
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29/09/2025
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SARNECKI, Zdzislaw
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Alcohol related
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08/09/2025
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19/09/2025
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MACHELL, Janet
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Janet Margaret MACHELL, did not die of natural causes because there were too many acts or omissions that probably contributed to her death.
1 Period 1 : Hospital Care before detention
(a) Failure to make a timely referral to Speech and Language Therapy (SALT)
(b) Inappropriate discharge from SALT whilst on the medical ward without physical assessment.
These probably contributed to Janet's death.
2 Period 2 : Circumstance around detention
(a) Janet did meet the criteria for detention under the Mental Health Act at the time it was determined to detain her.
(b) The decision to detain her possibly contributed to her death because it led to her being admitted to a mental health ward, namely Hurstwood Ward, where the staff providing her care were not sufficiently experienced or equipped to manager her complex physical health needs and subsequent deterioration.
(c) Janet was verbally informed of her rights under the Mental Health Act but probably did not understand them and there is no evidence of those rights having been given to her in writing. That failure possibly did contribute to her death.
(d) Janet's family were not told of the rights of appeal or that she had not been formally detained under s.3 of the Mental Health Act until such time as a bed was available for her. That possibly contributed to her death because her family have taken her home and/or appealed within the 14 days, once detention began.
3 Period 3 : Escalation of medical care
(a) Failure to appropriately record the NEWS score on 11/06/2023. It was at least 7 and probably closer to 10 in view of the lack of SATS reading.
(b) Failure to carry out observations commensurate to the NEWS score of 5.
(c) Failure, once Janet's blood dropped, to facilitate intervention by way of IV fluids or take further bloods.
(d) Lack of proper procedure for determining who is best placed to make the call to emergency services.
(e) Call to Ambulance Service was not placed by the person best placed to make it.
(f) Inadequate and unclear information given to the Ambulance Service leading to the inappropriate categorisation of the call as CAT4, resulting in avoidable delay in getting Janet to A&E for potentially life saving intervention.
(g) Failure to escalate the emergency call to clarify whether Janet was suffering from agonal breathing, which is likely to have resulted in the re-categorisation of the emergency call.
(h) Failure to use, or even consider using, oxygen when it was noticed that Janet's breathing had changed and/or when a change of colour in Janet's skin was observed and, at the latest, when it was determined she had a NEWS score of 7 without a SATS reading.
(i) Failure to carry out repeat physical observations every 15 minutes from the point at which the irregular heart rate and respiratory rates were observed.
These probably contributed towards Janet's death
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16/09/2025
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17/09/2025
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COYLE, Patrick Liam
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Patrick Liam COYLE died on the 10th March 2024 at 35 Victor Street, Clayton-Le-Moors, Accrington by hanging. Mr COYLE had struggled with his mental health for some time and had a recent, lengthy inpatient stay in a mental health hospital from which he had been discharged on the 4th March 2024.Mr COYLE did not want to be discharged from hospital. He struggled with alcohol addiction and, when intoxicated, his risks of impulsive behaviour and harm to himself increased. In the days since his discharge, Mr COYLE had been increasingly mentally unwell. He had used alcohol and consumed medication to excess. He expressed a desire to return to inpatient hospital care. Mr COYLE attended at accident and emergency on the 7th March 2024 where mental health workers assessed him as being safe to release. He was seen the following day at home by mental health support workers who noted that he denied current suicidal thoughts. Plans were made for ongoing support the following week but Mr COYLE was not heard from after the evening of the 8th March 2024. He was found dead on the 10th March 2024. It is not possible to determine Mr COYLE's intentions at the time he secured the ligature due to his intoxication and mental health deterioration prior to the act.
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18/09/2025
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18/09/2025
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CHAMBERS, Joseph Daniel
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Suicide
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22/09/2025
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22/09/2025
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McCALLUM, Stephanie
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Mrs Stephanie MCCALLUM died on the 11th January 2025 at the Royal Blackburn Hospital. Mrs MCCALLUM had suffered with significant headache, nausea and dizziness symptoms since December 2024 which were initially believed to be vertigo. Despite attendances at hospital and to her general practitioner, it was not identified that Mrs MCCALLUM was in fact suffering with poor blood flow in her posterior circulation due to furred basal artery. This was what had been causing her symptoms. On the 8th January 2025, Mrs MCCALLUM's health deteriorated and on the 9th January 2025 she was taken to hospital. A working diagnosis of stroke was assumed and whilst awaiting imaging scans to confirm diagnosis, Mrs MCCALLUM suffered a cardiac arrest following which she subsequently died. Mrs MCCALLUM's death was caused by an ischaemic stroke which in turn was caused by posterior circulation difficulties. Her underlying health conditions contributed to the furring of the artery which in turn caused her stroke.
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23/09/2025
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23/09/2025
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ALEXANDER, Sylvia Daphne
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Accident
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23/09/2025
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23/09/2025
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HALL, Jonathan Herbert
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Drug related
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23/09/2025
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23/09/2025
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SAOULI, Mohammed Aymen
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Drug related
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24/09/2025
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24/09/2025
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ASHTON, Scott
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Road traffic collision
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