Inquest Conclusions
Date of inquest Date inquest concluded Name of deceased Conclusion
20/09/2017 04/10/2017 MAZUREK, Marcin Miroslaw Marcin Mazurek moved to the segregation unit at his own request following allegations of threats and bullying. During that time there was an incident of deliberate self-harm. An ACCT document was opened. A lack of effective intervention, failure to explore alternative support options other than segregation, led to Mr Mazurek spending an inappropriate length of confinement in segregation (51 days). A lack of adherence to the ACCT requirements meant insufficient involvement and intervention of Mental Health professionals. There was inadequate reporting and recording by both discipline and medical teams, leading to an omission of multi-disciplinary working and communication. Ultimately, there was a lack of holistic overview of Mr Mazurek's concerns and a systemic failure to meet his needs. All of these factors probably contributed to Mr Mazurek's death.
04/10/2017 04/10/2017 BENNETT, Lee Misadventure
04/10/2017 04/10/2017 DOYLE, Sean Anthony Drug related
04/10/2017 04/10/2017 ROACH, Steven Suicide
04/10/2017 04/10/2017 STARKIE, Phillip Alcohol related
04/10/2017 04/10/2017 TOMLINSON, Alexander Mr Tomlinson died as a result of natural causes, on a background of cardiac changes brought about by drug experimentation.
05/10/2017 05/10/2017 OLVERSON, Damien Mr Olverson was found suspended by a ligature although the matter of intent is not made out in this case.
05/10/2017 05/10/2017 SMITH, Victoria Suicide
05/10/2017 05/10/2017 WALMSLEY, Garry Drug related death
10/10/2017 12/12/2017 CROSS, Kristina Mrs Cross died due to a sudden and catastrophic cardiac event, on a background of pre-existing cardiac changes and other medical conditions and the trauma of a traumatically fractured right femur, delayed surgical fixation and post-operative complications.
11/10/2017 11/10/2017 CLIFFORD, Patrick Mr Clifford fell backwards following a faint in the toilet on Ward B4 at the Royal Blackburn Hospital on the 19th March 2016. He suffered a fractured acetabulum as a result. This was treated conservatively. His condition deteriorated over time. He developed pneumonia due to immobility and heart failure and passed away on the 18th September 2016 at Springhill care home in Accrington.
11/10/2017 11/10/2017 CONNOR, Michael Drug related death
11/10/2017 12/10/2017 HYLAND, Anthony Natural causes
11/10/2017 11/10/2017 LYNAS, Melvyn Stuart Suicide
11/10/2017 11/10/2017 WOOD, Sean James Sean James Wood died on 5 May 2017 on Chancery Road, Chorley due to self inflicted suspension however there is insufficient evidence to find that he intended to end his own life.
12/10/2017 12/10/2017 CURWEN, Marion Mary Accidental death
12/10/2017 12/10/2017 DICKINSON, Glynn Barry Suicide
12/10/2017 12/10/2017 MONTGOMERY, Raymond Joseph Accidental death
12/10/2017 12/10/2017 WHELAN, Rose Nancy Jane Misadventure
17/10/2017 17/10/2017 RICHARDSON, Stuart Natural causes
17/10/2017 18/10/2017 SINGH, Avtar Natural causes
18/10/2017 18/10/2017 BOLTON, Gary Accidental death
18/10/2017 18/10/2017 GREEN, Shane Ian Natural cause
18/10/2017 18/10/2017 McCORDKINDALE, Tamara Skye Accidental death
18/10/2017 18/10/2017 SHERLOCK, Frederick Graham Industrial disease
24/10/2017 24/10/2017 CLARKSON, Carn Misadventure
24/10/2017 24/10/2017 HEARSEY, Gerald Industrial death
24/10/2017 24/10/2017 SHIRLEY, Kimberly Alcohol and drug related
25/10/2017 25/10/2017 DURKIN, Richard Alan Accidental death
25/10/2017 25/10/2017 FENN, Peter David Drug related death
25/10/2017 25/10/2017 MURTON, Julie Misadventure
25/10/2017 25/10/2017 SIMPSON, Lily Accidental Death
26/10/2017 26/10/2017 HODGSON, Joan On 10 June 2016 in an unwitnessed fall at her home 16 Holland Avenue, Walton le Dale, Joan Hodgson suffered a head injury the treatment for which at Royal Preston Hospital included the administration of anti-coagulant medication which was not appropriately managed resulting in her death on 15 June 2016.
27/10/2017 27/10/2017 STANCHEV, Plamen Tilev Suicide
31/10/2017 02/11/2017 DALE, David David Dale died as the result of a road traffic collision.
31/10/2017 31/10/2017 KNOWLES, Carole Anne Natural cause
31/10/2017 31/10/2017 RAILTON, Stuart Accidental Death
01/11/2017 01/11/2017 GARNETT, Jill Accidental Death
01/11/2017 01/11/2017 HARTLEY, Lee Andrew Suicide
06/11/2017 28/11/2017 TALBOT, Christopher Shaun There was a failure with regards to monitoring the situation at the cell and subsequent lack of intervention which probably contributed towards to death.
07/11/2017 07/11/2017 HARVEY, Margaret Mrs Harvey was diagnosed with mesothelioma, a condition brought about by the exposure to asbestos, however in this case the evidence as to the source of that exposure is lacking.
08/11/2017 08/11/2017 BINNS, Alan Natural cause
08/11/2017 08/11/2017 BRADLEY, Dawn Alcohol related
08/11/2017 08/11/2017 HUTCHINSON, John Suicide
08/11/2017 08/11/2017 Manawar, Shakeel Road traffic collision
09/11/2017 09/11/2017 DAINTY, Andrew Suicide
09/11/2017 09/11/2017 SUTHERLAND, Paul Suicide
13/11/2017 13/11/2017 BEAN, Richard Road traffic collision
13/11/2017 13/11/2017 HOWARTH, Christopher William Mr Howarth died as a direct result of mesothelioma, a condition brought about by asbestos exposure, however the source of that exposure is not evidenced in this matter.
13/11/2017 13/11/2017 Nevett, Margaret Anne Misadventure
13/11/2017 13/11/2017 ZHANG, Yusen Road traffic collision
14/11/2017 14/11/2017 COOPER, John Drug related death
14/11/2017 14/11/2017 SAVAGE, Frederick Suicide
15/11/2017 15/11/2017 HARDMAN, Peter Francis Albert Drug related
15/11/2017 15/11/2017 MITCHINSON, Eric Natural cause
15/11/2017 15/11/2017 TAYLOR, Vicky Misadventure
15/11/2017 15/11/2017 TORMEY, Brian John Bosco Natural causes
16/11/2017 24/11/2017 COATES, Stephen Lewis The jury believe the commencement time of the recordable observations was 11:30 pm on the 8th April. The time was arrived at by estimates for the cell key holders and the nurse and assistant to arrive at the cell after the cell bell had been rung, with an allowance given for introductions and initial health related questions. Yes, the nurse should have taken a full set of observations within an hour of the first set. This was evidenced by the expert witnesses. The jury has arrived at a unanimous decision, based on the evidence and timings given by expert witnesses that Stephen COATES would have arrived at Accident and Emergency within two hours of his first observations being taken. On the balance of probabilities Stephen COATES would have survived. The decision was arrived at by accepting expert witness evidence. The jury agree that there was a gross failure to provide basic medical care to Stephen COATES. The jury have come to the conclusion that by the nurse not taking a full set of observations and a subsequent second set with follow up actions when the opportunity arose Stephen COATES' basic medical care was not met. And from that Stephen COATES' subsequent death was contributed to by neglect.
16/11/2017 16/11/2017 MALKOWSKI, Wojciech Suicide
20/11/2017 20/11/2017 DOWLING, Frederick Joseph Natural Causes
20/11/2017 20/11/2017 MARSLAND, Donald Industrial disease
20/11/2017 20/11/2017 TATE, Arnold Accident
21/11/2017 21/11/2017 PALMER, John Industrial disease
22/11/2017 22/11/2017 BERNARD, Ann Bernette Accidental death
22/11/2017 22/11/2017 Clayton, Stanley Stanley Clayton died at 3 Thirlmere Avenue, Burnley on 12 June 2017 from a lung cancer having been exposed to asbestos during his working life.
22/11/2017 22/11/2017 RAWSON, William Industrial disease
23/11/2017 23/11/2017 SAYERS, Peter Henry Peter Henry Sayers was found deceased on the 31st January 2017 at Flat 23 Maudland House Preston from an unknown cause.
27/11/2017 27/11/2017 SIMONS, Stephen Suicide
29/11/2017 29/11/2017 HEWITT, Rachael Sarah Drug related death
30/11/2017 30/11/2017 EDGERTON, Kenneth Natural Causes
30/11/2017 30/11/2017 McLOUGHLIN, Roman Accidental Death
05/12/2017 05/12/2017 BLACKBURN, Bryan Accidental death
05/12/2017 05/12/2017 HODSON, John Accidental death
05/12/2017 07/12/2017 TAYLOR, Beverley Louise Beverley Louise Taylor died on 13 March 2015 at Royal Lancaster Infirmary. Ms Taylor was profoundly handicapped after sustaining herpetic encephalitis. Ms Taylor was admitted with a severe bronchopneumonia caused by infection and aspiration and her death was contributed to by inadequate antibiotic therapy and minimally by fluid overload.
06/12/2017 06/12/2017 MASON, Kenny Francis Suicide
06/12/2017 06/12/2017 MOODY, Maurice Accidental death
11/12/2017 11/12/2017 KIRKPATRICK, Ian Misadventure
12/12/2017 12/12/2017 BOAST, Liam Patrick Suicide
12/12/2017 12/12/2017 COXON, Anne Open
12/12/2017 12/12/2017 ELLIOT, Andrew John Drug related death
12/12/2017 12/12/2017 JOEL, Christopher Allan Undiagnosed natural cause
13/12/2017 13/12/2017 WAITE, Henry Henry Waite died at Royal Albert Edward Infirmary Wigan following elective hip surgery on 13th February 2017. Post operatively he was discharged for rehabilitation where he suffered an unwitnessed fall on 23rd February leading to a 2nd operation on 25th February whereafter he died on 6th April 2017 from an infection.
13/12/2017 14/12/2017 WRIGHT, Stuart Drug related death
14/12/2017 14/12/2017 KEARNS, Paul Anthony Miadventure
18/12/2017 18/12/2017 HAGGETT, Paul Ian Suicide
18/12/2017 18/12/2017 MCINTOSH, Joanne Suicide
19/12/2017 19/12/2017 BAYNE, Dudley James Road Traffic Collision
19/12/2017 19/12/2017 FORREST, Phillip Suicide
19/12/2017 19/12/2017 Oliver, Karl Karl Joseph Oliver was found dead on 4th May 2017 at Flat 1, 11a Market Street, Carnforth. His death is more likely to be epilepsy related.
20/12/2017 20/12/2017 CHAN, Tak Wai Unknown natural cause
20/12/2017 20/12/2017 HODKINSON, Wayne Suicide
20/12/2017 20/12/2017 WEBSTER, George Accidental death
21/12/2017 21/12/2017 DUFFY, Thomas Mark Drug related death
21/12/2017 21/12/2017 KENNEDY, Darrell Drug related death
21/12/2017 21/12/2017 O'BRIEN, Paul Patrick Drug related death
22/12/2017 22/12/2017 COOPER, Brian Brian Joseph Cooper died of a misadventure.
22/12/2017 22/12/2017 HARGREAVES, Sandra Elizabeth Natural causes
22/12/2017 22/12/2017 REID, Philip Natural causes
22/12/2017 22/12/2017 SANDS, David Natural causes
22/12/2017 22/12/2017 TUNNACLIFFE, Barbara Mary Barbara TUNNACLIFFE died on 12 November 2017 following a fall down the stairs at her home address caused by underlying natural causes.
03/01/2018 03/01/2018 HINDLE, Shane John Ronald Drug related death
08/01/2018 08/01/2018 ASHWORTH, Sheila Accident
08/01/2018 08/01/2018 JUREK, Marcin Piotr Road traffic collision
08/01/2018 08/01/2018 KERSHAW, Keith Misadventure
08/01/2018 08/01/2018 MURGATROYD, Stewart Peter Alcohol and drug related
08/01/2018 08/01/2018 NUTTALL, Fred Industrial disease
08/01/2018 08/01/2018 WALLACE, June Mrs Wallace died as a result of mesothelioma, a condition linked to asbestos exposure, however the exact nature of asbestos exposure is not clear in this instance.
08/01/2018 08/01/2018 WALSH, Donna Drug and alcohol related death
08/01/2018 08/01/2018 WARBURTON, John Hilton Drug related death
08/01/2018 08/01/2018 WEBSTER, Andrew Joseph Alcohol related death
09/01/2018 09/01/2018 Graham, Sharon Alcohol Related Death
09/01/2018 09/01/2018 Longton, Zoe Alcohol related death
09/01/2018 09/01/2018 Williamson, John Suicide whilst the balance of his mind was disturbed.
10/01/2018 10/01/2018 Cropper, Jack Suicide
10/01/2018 10/01/2018 Gold, Simon Drug related death
11/01/2018 11/01/2018 BALL, Alison Suicide
11/01/2018 11/10/2018 BROWN, Karl Frederick Suicide
11/01/2018 11/01/2018 FLEMMING-CRUISE, Nathan Miuchael Suicide
11/01/2018 12/01/2018 HENDERSON, Thomas Albert Thomas Albert HENDERSON died from natural causes, although his death was contributed to by the effects of therapeutic morphine which had been prescribed to provide him with pain relief.
11/01/2018 11/01/2018 HILLS, William Geoffrey Accident
11/01/2018 11/01/2018 JONES, Dian Thomas Misadventure
11/01/2018 11/01/2018 OTLEY, Philip Walter Accident
15/01/2018 15/01/2018 BARGIT, Mustaq Mohammed Natural Cause
15/01/2018 15/01/2018 BELL, Jean Amy Accidental death
15/01/2018 15/01/2018 CRITCHLEY, Brian Accidental death
15/01/2018 15/01/2018 GROGAN, Alan Suicide
15/01/2018 15/01/2018 WILSON, Sarah Natalie Road traffic collision
16/01/2018 18/01/2018 HARLAND, Elton Lyndon Kevin Narrative Conclusion At a time between 21:14 hours on the 6th April 2016 and 14:47 hours on the 7th April 2016 Elton Harland suspended himself with an ethernet cable (which formed a ligature) from the top of the shower cubicle in the ensuite of his bedroom at Orchard House. This action resulted in his death. The question of intent remains unclear.
22/01/2018 22/01/2018 BARLOW, Jaime Marie Drug related death
22/01/2018 22/01/2018 BRYCE, Paul Michael Suicide
22/01/2018 22/01/2018 FARR, Philip Suicide
24/01/2018 24/01/2018 Thompson, Brian Misadventure
25/01/2018 25/01/2018 DUDDLE, Margaret Dorothy Accident
29/01/2018 29/01/2018 KAYSER, Michal Maciej At 06:30am on the 23rd July 2017 Mr Kayser was involved in a single vehicle collision on the A680 Blackburn Road. Mr Kayser was the sole occupant of a Nissan motorcar, when he applied the handbrake, causing the vehicle to spin into a solid wall, sustaining catastrophic damage and resulting in fatal injuries to Mr Kayser. Despite transfer to the Royal Preston Hospital where medical intervention was attempted, Mr Kayser died at the Royal Preston Hospital on the 28th July 2017.
31/01/2018 31/01/2018 MOFFATT, Danny Drug related death
31/01/2018 01/02/2018 OAKLEY, Duval Natural causes
31/01/2018 31/01/2018 SAUNDERS, David Suicide
06/02/2018 06/02/2018 WOODBURN, Cy Scott Natural causes
06/02/2018 06/02/2018 WOOLF, John Roy Accidental death
07/02/2018 07/02/2018 CARTER, Claire Louise Drug related death
07/02/2018 07/02/2018 DEAN, Mark Anthony Drug related
07/02/2018 07/02/2018 HUNT, Amy Charlotte Suicide
07/02/2018 07/02/2018 PARRATT, Raymond John Industrial disease
07/02/2018 07/02/2018 PICKUP, James Road Traffic Collision
07/02/2018 07/02/2018 PRICE, Gary James Drug related death
12/02/2018 12/02/2018 WOOD, Michael Charles Suicide
13/02/2018 13/02/2018 BUNTING, Joan Accidental death
14/02/2018 14/02/2018 RAYTON, Mark Suicide
16/02/2018 16/02/2018 FLETCHER, Jack Accident
16/02/2018 16/02/2018 LYONS, Doreen Hannah Alcohol related death
16/02/2018 16/02/2018 MARSH, Carl Anthony Misadventure
16/02/2018 16/02/2018 PAUL, Matthew Vernon Misadventure
16/02/2018 16/02/2018 WILCOCK, Carol Elizabeth Alcohol related death
20/02/2018 20/02/2018 DONNELLY, Paul Andrew Misadventure
21/02/2018 21/02/2018 ROBINSON, Keith Road Traffic Collision
26/02/2018 26/02/2018 DUFFY, Barbara Accident
26/02/2018 26/02/2018 HALLIDAY, Raymond Drug related death
26/02/2018 26/02/2018 HOBBS, William Harry Accidental Death
26/02/2018 26/02/2018 JACKSON, John Industrial Disease
26/02/2018 26/02/2018 KELLY, Betty Betty Kelly died at Royal Blackburn Hospital on 5th June 2017 having ingested an excess of prescribed medication, however there is insufficient evidence to determine how and in what circumstances it was taken.
26/02/2018 26/02/2018 MCIVOR, Oliver Lewis Natural cause
26/02/2018 26/02/2018 MCKAY, Milani Evelyn Louise Milani Evelyn Louise McKay died on 8th March 2017 at Royal Blackburn Hospital having fallen asleep with her father. There is insufficient evidence to say whether that played a part in her death.
26/02/2018 26/02/2018 SULIGA, Tomasz Józef Drink related death
27/02/2018 27/02/2018 BUTLER, Lee Misadventure
27/02/2018 27/02/2018 IRELAND, Frances Natural cause
27/02/2018 27/02/2018 NEVETT, Margaret Accident
27/02/2018 27/02/2018 ROGERS, Martin Junior Accident
28/02/2018 28/02/2018 HAY, Eric Suicide whilst the balance of his mind was disturbed
28/02/2018 28/02/2018 HILL, Sheila Misadventure
28/02/2018 28/02/2018 MCCRUDDEN, Tracie Michelle Death by hanging
28/02/2018 28/02/2018 RAWSTHORNE, Howard Leslie Misadventure
05/03/2018 05/03/2018 BILLINGTON, George Industrial disease
05/03/2018 05/03/2018 BURGESS, Stanley Industrial disease
05/03/2018 05/03/2018 LOVE, Edna Joyce Accidental Death
05/03/2018 05/03/2018 WHITTLE, Paul Accident
06/03/2018 06/03/2018 BORKOWSKI, Tadeusz Suicide
06/03/2018 06/03/2018 HOGARTH, Pauline Misadventure
06/03/2018 06/03/2018 POWNALL, Gregory Mr Pownall died as a result of a rare but recognised complication of the elective abdominal aortic aneurysm repair procedure.
06/03/2018 06/03/2018 TODD, Brenda Misadventure
07/03/2018 07/03/2018 BAIN, Graham Suicide
07/03/2018 07/03/2018 BATEMAN, Steven Suicide
13/03/2018 13/03/2018 CARROLL, Stanley Accident
13/03/2018 13/03/2018 JOHNSTON, Wayne Misadventure
13/03/2018 13/03/2018 LINDSAY, Dorothea Lillian Dorothea Lillian Lindsay died on 25 December 2016 at Southport District Hospital as a result of frailty of old age and significantly contributed to by a sacral pressure ulcer that developed due to an absence of adequate pressure area treatment between 14 and 19 November 2016
14/03/2018 14/03/2018 BURGESS, Mary Foster Accidental death
14/03/2018 14/03/2018 CRAIG, Robert William Lyman Mr Craig died as a result of self suspension by a ligature although intent is not fully made out on the evidence.
14/03/2018 14/03/2018 HEAPS, Calvin John Accidental death
14/03/2018 14/03/2018 HUGHES, Marjorie Accident
19/03/2018 19/03/2018 EDMONDSON, Paul Suicide
19/03/2018 19/03/2018 HOWARD, Steven Jason Suicide
21/03/2018 21/03/2018 CARTER, Thomas Misadventure
21/03/2018 21/03/2018 HEATON, Neil Accident
21/03/2018 21/03/2018 JACQUES, George Colin Industrial disease
21/03/2018 21/03/2018 PROCTOR-BARR, Angus Drug related death
21/03/2018 21/03/2018 SMITH, Rachel Diane Shearson Accident
This is the only information that can be provided at this time.