The Article 2 Inquest into the death of CT concluded in December 2025. The inquest was heard over 5 days at Blackpool & Fylde Coroner’s Court before HM Area Coroner Margaret Taylor.

CT died on 28 November 2024 as a result of a Pulmonary Embolism secondary to a Deep Vein Thrombosis (DVT) of the right leg veins. Ordinarily referred to as a blood clot, the Jury found that a combination of failings and inadequacies in respect of CT’s care contributed to her death.

The Jury determined, on the balance of probabilities, that had additional and / or alternative treatments been provided, these would have prevented her death.

Circumstances Leading Up to CT’s Death

CT had a diagnosis of recurrent depressive disorder with severe psychosis. She had been known to mental health services since early 2018.

On 19 September 2024, CT was admitted to Austen Ward at the Harbour Hospital under s.3 of the Mental Health Act 1983. Upon admission to Austen Ward, CT was not eating or drinking. The Jury heard evidence that food and fluid intake remained minimal for the duration of CT’s admission; this being a symptom of her severe depression.

Throughout her admission, CT suffered from a complex neuropsychiatric syndrome known as ‘catatonia’. Catatonia is a syndrome that can manifest in a number of ways including unresponsiveness, lack of movement and speech, and resistance to instruction or attempts to be moved. The Jury heard evidence that CT would frequently resign into a ‘catatonic’ state, resulting in recurrent periods where CT was unable to move or communicate with staff.

Within 24 hours of her admission to Austen Ward, a Venous Thromboembolism (VTE) Risk Assessment was carried out by a doctor. On the basis of the evidence heard, the Jury reasoned that CT was, at the time of her admission, at risk of developing a DVT for the following reasons: –

  • Her age (she was over the age of 60)
  • Her lack of mobility
  • The side effects of her anti-psychotic prescribed medication
  • Her intermittent catatonia
  • Dehydration

Not withstanding these identifiable risks, the Jury heard evidence that significant criteria were omitted from the VTE assessment conducted on admission, with CT’s age being the only risk identified by the assessing doctor. CT was, in the circumstances, assessed as not presenting with clinical risk factors of VTE upon admission and it was deemed that this was likely the result of the assessing doctor not conducting the assessment face-to-face, in conjunction with their failure to consult CT’s family for collateral information. This resulted in what the Jury described as an inadequate and incomplete assessment taking place.

Despite the limitations of the initial VTE assessment, CT was, nonetheless, prescribed an anticoagulant medication known as “Dalteparin” which works to prevent serious blood clots like a DVT or Pulmonary Embolism from forming by cascading the clotting process. It was recognised by the prescribing pharmacist that CT had been taking this medication at the hospital from which she was transferred, and the medication was therefore administered, despite the outcome of the VTE assessment, on the basis that the medication should continue until she had settled onto the ward.

CT’s prescription of Dalteparin did however continue for the 10-weeks that she remained an inpatient on Austen Ward and this was to be administered by way of an injection daily. During the course of the proceedings however, it was accepted that CT only received 4 of the daily injections available to her in the 10-weeks of her admission. The reasons for this were explored as part of the inquest with staff primarily noting that they were unable to obtain CT’s consent to administer the medication owing to the frequency of her catatonic episodes.

Per Trust policy, where incidents of patients not accepting or refusing prescribed medication are identified, this should be recorded on the Trust Incident Recording system to enable a review by the Trust’s governance team. The Jury heard evidence that CT’s non-acceptance of Dalteparin was never documented on said system, nor was there any discussion amongst staff as to alternative strategies that might be imposed to ensure that physical health medication, such as Dalteparin, was being administered. It was ultimately agreed that ward staff appeared to have prioritised CT’s mental health over her physical health needs.

On the morning of 28th November 2024, CT sadly collapsed on the ward and became unresponsive. CT was transferred to Blackpool Victoria Hospital; however, she sadly died the same day as a result of a Pulmonary Embolism secondary to a DVT of the right leg veins.

An Expert Witness in haematology gave evidence at the inquest that the use of anticoagulant medication (such as Dalteparin) in patients where there is an increased risk of VTE, can reduce the risk of a patient developing a DVT or Pulmonary Embolism up to 70%. On this basis, it was reasoned that 70% of DVTs can effectively be prevented where anticoagulant medication is properly administered to a patient.

The Jury’s Conclusion

The following conclusions were made by the Jury’s as to CT’s death: –

  • The VTE assessment CT received on admission to the ward was not an adequate or complete assessment and significant criteria were omitted.

  • CT’s risk of VTE was unsatisfactorily monitored whilst she was on the ward.

  • The care that CT received and the treatment provided was not effective in mitigating the risk of developing a DVT / Pulmonary Embolism.

  • CT experienced reduced mobility whilst on Austen Ward and the plans in place to improve her mobility were inadequate.

  • Staff did not take appropriate or adequate action to address CT’s ability to engage with treatment for any physical health conditions, including ensuring that medication was taken.

  • CT could have received additional or alternative treatment which would have effectively reduced her risk of developing a DVT / Pulmonary Embolism.

It was ultimately concluded that if additional and / or alternative treatment had been provided to CT, these treatments, on the balance of probabilities, would have prevented her death at Blackpool Victoria Hospital on 28 November 2024.

CT’s family were represented throughout the proceedings by Kelly Darlington, Partner at Farleys Solicitors and Gareth Thompson of St. John’s Buildings.