PFD report

Margaret Clement · Prevention of Future Deaths report

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Issued 14 May 2024•Lancashire and Blackburn with Darwen

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Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns: 6
Recipients: 1
Responses found: 1
Stated actions: 12

Recipients and published responses

Lancashire Teaching Hospitals NHS Foundation TrustNo response found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 23 June 2022 I commenced an investigation into the death of Margaret Clement (92 years old). The investigation concluded at the end of the inquest on 8 May 2024. The conclusion of the inquest was:

Margaret CLEMENT died on 15 June 2022 at Royal Blackburn Hospital, Blackburn. Following a fall, Mrs CLEMENT was admitted to hospital where a fractured neck of femur was diagnosed and operated upon on 23 May 2023. Mrs CLEMENT was prescribed anticoagulation following the operation to reduce the risk of clotting. She was discharged to Pendle Community hospital for rehabilitation on 10 June 2022. She had suspected melaena in the evening on 12 June 2022. She then developed significant rectal bleeding in the morning of 14 June 2022 and was admitted to Royal Blackburn Hospital following vomiting blood later in the evening. An upper gastrointestinal bleed was then diagnosed which led to a cerebrovascular accident from which she did not recover

Concerns and recipient responses

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Concerns raised6

Failure to seek urgent clinical assistance for significant per rectum bleeding
Part of recurring concern: Failure to seek medical attention when a person's condition warrants it Part of recurring concern: Failure to take timely escalation action when safety thresholds are breached
Inadequate nursing handovers failing to ensure appropriate risks are managed and prioritised
Part of recurring concern: Unreliable clinical handover processes
Inadequate nursing records
Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records

Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response 11

Action
Use the approved divisional report template to govern PSII action plans through the Corporate Patient Safety Group and escalate delays or problems for discussion and support.
Stated by East Lancashire Hospitals NHS TrustStated completed
Action
Remove doctors’ task books and route non-urgent requests through Cerner, with urgent concerns verbally escalated to medical staff or the Acute Care Team.
Stated by East Lancashire Hospitals NHS TrustStated completed
Action
Provide daily multidisciplinary meetings and twice-daily medical-team handovers to the Acute Care Team to identify concerned patients and support timely deterioration management.
Stated by East Lancashire Hospitals NHS TrustStated completed

Action
Arrange simulation-based deterioration training for community-ward staff, including assessment, escalation, handover, documentation and gastrointestinal-bleeding scenarios.
Stated by East Lancashire Hospitals NHS TrustStated completed
Action
Update the central action-monitoring process by adding Patient Safety Group assurance requirements and informing divisions to include PSII action-plan monitoring in governance meetings.
Stated by East Lancashire Hospitals NHS TrustStated completed
Action
Display the ward escalation plan with staged escalation requirements, observation frequencies and staff responsibilities, supported by staff awareness and training.
Stated by East Lancashire Hospitals NHS TrustStated completed
Action
Update SOP046 to require medical and nursing staff to verify completion of doctors’ tasks before leaving the ward.
Stated by East Lancashire Hospitals NHS TrustStated planned
Action
Enable nursing staff to accompany doctors on ward rounds and use the daily multidisciplinary meeting to escalate concerns and immediate actions.
Stated by East Lancashire Hospitals NHS TrustStated completed
Action
Administer and update medications through Cerner scanners, with senior-nurse observations and governance monitoring of wristband and medication-administration compliance.
Stated by East Lancashire Hospitals NHS TrustStated completed
Action
Monitor recommendations from the SOP046 audit through a SMART action plan overseen by the Trust Clinical Audit team.
Stated by East Lancashire Hospitals NHS TrustStated in progress
Action
Standardise clinical-risk handovers by using Cerner tasks and embedding Patient e-Obs trend review during nursing handover.
Stated by East Lancashire Hospitals NHS TrustStated completed

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 1

1
Update doctors’ guidance documents to reflect the revised ward escalation and task-management processes.
Stated by East Lancashire Hospitals NHS TrustStated completed

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised6

Failure to seek urgent clinical assistance for significant per rectum bleeding

Inadequate nursing handovers failing to ensure appropriate risks are managed and prioritised

Inadequate nursing records

Inadequate assessment of compliance with procedural changes and expectations

Failure of doctors to prioritise work by reviewing the task book for urgent tasks

Failure to request medical review verbally when appropriate

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.11

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

Actions described in response 11

Recipient-stated actions 1