A coroner has raised concerns about Royal Blackburn Hospital after a grandmother had a stroke after losing a significant amount of blood and died.

A report, which highlights "inadequate care" from hospital staff, has been sent to the East Lancashire Hospitals NHS Trust, which manages the hospital, so action can be taken to “prevent future deaths” from occurring. 

East Lancashire Hospitals said it “regrets” that the quality of care “fell short of [its] usual standards”.

Margaret Clement died at Blackburn Hospital on June 15, 2022, aged 92.

Following a fall, Mrs Clement was admitted to Royal Blackburn where she was diagnosed with a fractured neck of the femur (broken hip) which was operated on.

Mrs Clement was prescribed anticoagulation medication following the operation to reduce the risk of blood clotting.

She was discharged to Pendle Community Hospital for rehabilitation on June 10, 2022.

She had suspected melaena (blood in faeces) on June 12, and then developed significant rectal bleeding in the morning of June 14 and was admitted to Royal Blackburn Hospital after vomiting blood.

She was diagnosed with an internal bleed which caused a stroke, resulting in her death.

The coroner commenced an investigation into Mrs Clement’s death on June 23, 2022. The inquest concluded on May 8 this year.

Christopher Long, area coroner for Lancashire and Blackburn with Darwen, has issued a prevention of future deaths notice containing a series of recommendations for the ELHT to consider.

Mr Long believes there “is a risk future deaths could occur unless action is taken” and highlighted some matters of concern to the trust.

Evidence was heard that nursing records on the ward “were inadequate”. The report said medication was incorrectly recorded and that a medical review was "requested for the wrong patient”.

Evidence was also heard that nursing handovers were “inadequate” and “did not ensure appropriate risks were managed and prioritised”.

Doctors on the ward were said not to “effectively prioritise work” and nurses were said to have failed to seek urgent help when they learned about Mrs Clement’s significant bleeding.

ELHT has a duty to respond to the coroner and address these concerns by July 10.

The trust said “valuable lessons have been learned” from this experience adding efforts have been taken to “enhance the response to patients' deteriorating conditions”.

Executive medical director at East Lancashire Hospitals Trust, Jawad Husain, said: “Our condolences go out to Mrs Clement’s family for their loss, and we regret that the quality of care she received fell short of our usual standards.

“In response to the incidents surrounding Mrs Clement's death, the Trust implemented two comprehensive action plans. Valuable lessons have been learned from this experience and have been shared with colleagues.

“Efforts have been made to enhance the response to patients' deteriorating conditions, focusing on improved communication and the establishment of a dedicated 'call for concern' hotline.

"This hotline offers an avenue for anyone who observes a patient's condition decline to seek urgent, independent review if they have concerns.”