A lack of staffing on a bank holiday Monday contributed to the death of a man on the mental health ward at a Blackburn hospital, a coroner has found.
David Lennox Stewart died on August 27, 2025, after suffering from a complex medical history.
In the weeks prior to his death, the 63-year-old had a long hospital admission before transferring to an acute mental health ward.
A coroner's conclusion said: “The mental health ward was not suitable for a patient with such significant physical health needs.
“Mr Stewart declined some medical treatments, but ward staff did not record observations and escalations were slow.”
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Red flag symptoms of physical deterioration were not identified as a medical emergency by medical staff and the bank holiday weekend staffing limited escalation options, the coroner added.
His oral intake was also not consistently recorded which contributed to dehydration and the development of ketoacidosis.
The coroner stated: “Mr Stewart died as a consequence of severe euglycemic ketoacidosis. His care on the mental health ward contributed to his severe condition and his death.”
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