Janet Springall

Coroner's concerns

AI summary

Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.

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In the circumstances it is my statutory duty to send the report:

The MATTER OF CONCERN is as follows. –

My concern is that notwithstanding the hospital Trust seems to have made welcome improvements, patients such as Janet Springall remain at risk. The Trust continues to experience significant pressures due to patient numbers, and unwell patients continue to remain in ambulances for some time before they are able to access the emergency department. When a very unwell patient has to remain on an ambulance due to very high demands placed upon a hospital emergency department, believed by paramedics to have a life-threatening infection, then in the absence of a blood test and the timely administration of any necessary intravenous fluids and antibiotics, the chances of such a patient surviving can be significantly reduced by the time the patient is able to access the emergency department. Janet Springall was very unwell by the time she arrived at hospital and was likely to die. Any realistic prospect she may recover had subsided by around 7.30pm, some 2.5 hours after arrival at hospital. Other patients may not be as unwell as Janet was upon arrival at hospital, and may therefore have more chance of surviving, but they too may deteriorate significantly whilst remaining in the ambulance before it can be confirmed they have an infection and receive timely medical attention and treatment.

I believe it is necessary for to raise this concern, but it is not for me to be prescriptive about what should / can be done.

Responses

2 respondents

Department for Health and Social Care Central Government

22 May 2026 PDF

Action Planned

• The Department of Health and Social Care and NHS England published the 2025/26 Urgent and Emergency Care Plan, the Medium Planning Framework 2026-27 to 2028/29, and the 10-Year Health Plan for England. • These plans set out priorities including reducing ambulance response times, eliminating handover delays, and improving hospital flow. • Over £370 million in national capital funding has supported these improvements. (AI summary)

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Dear Mr Wilson,

Thank you for the Regulation 28 report of 9th February 2026 sent to the Secretary of State / the Department of Health and Social Care about the death of Janet Springall. I am replying as the Minister with responsibility for Health.

Firstly, I would like to say how saddened I was to read of the circumstances of Janet Springall’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.

The report raises concerns over the continued pressure experienced in the emergency department in Blackpool Teaching Hospital NHS Trust causing patients to remain in ambulances despite needing immediate care within the department.

In preparing this response, my officials have made enquiries with NHS England and Blackpool Teaching Hospital NHS Trust to ensure we adequately address your concerns. CQC have advised they will be providing a separate response to your concerns.

DHSC and NHS England Actions

NHS England and the Department of Health and Social Care recognise the ongoing pressures across urgent and emergency care, including ambulance services. To improve the quality and timeliness of patient care, the Department of Health and Social Care and NHS England published the 2025/26 Urgent and Emergency Care Plan (June 2025), the Medium Planning Framework 2026-27 to 2028/29 and the 10-Year Health Plan for England: Fit for the Future (July 2025). These set out key system priorities:

• reducing ambulance response times
• eliminating handover delays over 45 minutes and ending corridor care
• improving hospital flow and discharge

• expanding urgent care access across primary, community, and mental health settings

Over £370 million in national capital funding supported these improvements. The plans also commit to shifting focus from treatment to prevention, reducing pressure on urgent and emergency care. To ensure timely patient care and release ambulances back into the community, the plan mandates the “Release to Rescue” approach. This requires the handover process to begin at 30 minutes and be completed by 45 minutes.

NHS England continues to work with ICBs, acute trusts, and ambulance services to deliver the 45-minute maximum handover requirement, strengthen urgent community care, and improve hospital flow and discharge. Risks associated with long community waits for ambulances are regularly discussed at national forums to support shared understanding and coordinated action across the urgent and emergency care system. The Medium-Term Planning Framework (2026/27–2028/29) sets further ambitions for acute and ambulance collaboration, including progress toward the 15-minute handover standard.

Local Actions

Following the sad death of Ms Springall a Patient Safety Incident Investigation (PSII) involving North West Ambulance Service (NWAS) was conducted by Blackpool Teaching Hospitals NHS Trust (BTHT) under the Patient Safety Incident Framework.

The investigation highlighted Ms Springall’s attendance at the emergency department via ambulance transfer during a period of extreme pressure with the Trust was operating at OPEL 4 and ambulance handover escalation protocols should have been activated. Investigation findings noted that although Ms Springall presented with significant risk factors, the triage assessment was inaccurate, did not acknowledge her recent admission, and did not consider sepsis despite Trust guidance requiring this on presentation. The report highlighted the following key findings:

• Missed opportunities: Sepsis screening was not completed, escalation to a senior decision-maker (SDM) did not occur, and there was no clear patient ownership while she waited without a physical ED bed space.
• Documentation gaps: The triage nurse’s retrospective statement lacked detail, and escalation actions were unclear.
• Significant delays in assessment and treatment occurred.

In response to the findings BTHT have:
• Implemented the maximum ambulance handover time of 45 minutes, with a review to confirm embedding of policy scheduled for April 2026.

• Additional training and education has been delivered to all ED nursing staff in recognising sepsis and the sepsis pathway.

• The Trusts Learning Disabilities Team now regularly attends ED safety days highlighting the importance of obtaining history from families.
• The ICB has overseen the implementation of a range of national and regional initiatives across Lancashire and South Cumbria Trusts with the aim to reduce the incidents of people being held outside EDs as a result of crowding with the departments and through the hospitals.

The introduction of ‘Handover 45’ is a significant change from previous policy that outlined an escalation period at 8 hours. Work to reduce the current variation in compliance with Handover 45 is in place at site, trust, place and system, levels with oversight of progress via the UEC governance structures including Strategic Ambulance Improvement Group reporting into the Strategic System Improvement Group.

There are UEC improvement plans in place across all Place and Trust teams that describe how local schemes relating to the improvement of flow lead to the delivery of the ICB’s UEC strategy. BTHT has been in Tier 1 for UEC since August 2025, requiring fortnightly reporting to NHS England on UEC performance improvements. As a result of being a Tier 1 site, they have benefitted from Getting It Right First Time UEC on-site clinical and operational improvement resource.

In addition, the Regional Head of Learning Disability & Autism has confirmed that the ‘Learning from Lives and Deaths- people with a learning disability and autistic people’ (LeDeR) review for this case is underway and is focusing on learning around:

• Journey prior to hospital admission – signs of deterioration, actions taken, support in the community
• Reasonable adjustments / support while waiting (during conveyance to A&E and within A&E)

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Care Quality Commission

PDF

Received

No AI summary available.

Report sections

Investigation and inquest

The death of Janet Springall on 27th January 2025 was reported to me and I opened an investigation, which concluded by way of an inquest on 22nd January 2026.

I determined that the medical cause of death was: 1a Sepsis 1b Pneumonia

II Rheumatoid arthritis on immunosuppressant medication

In box 3 of the Record of Inquest I recorded as follows:

Janet Springall was aged 68 years. She had a learning disability and her medical history included previously diagnosed rheumatoid arthritis for which she was treated with immunosuppressant medication, placing her at increased risk of developing infection. After a period of six weeks in hospital, she was discharged to a care home on 10th January 2025 where she was visited regularly by her Sister. She could be reluctant to accept food and fluids. From approximately late afternoon on Thursday 23rd January 2025 she ate very little and ingested minimal fluids. On Sunday 26th January 2025 at shortly before 1.30 pm her Sister arrived to visit Janet and found her unresponsive but breathing. It is reported that a carer had seen Janet around fifteen minutes earlier, when Janet had rejected her medication but otherwise raised no concerns. From the available evidence, it cannot be stablished exactly when her condition began to deteriorate, but the deterioration had not been fully appreciated, thereby reducing the chances of Janet making a full recovery. An ambulance was requested and upon arrival, a paramedic found Janet unresponsive and hypoglycaemic. With medical assistance including intravenous glucose, she revived and was transferred to the local accident & emergency department where she was triaged at 16.58 hours that afternoon. Due to the very high number of patients in the department that day, many including Janet had to remain on ambulances. Over subsequent hours, her condition remained concerning and on occasions a paramedic sought to escalate her care with hospital staff but capacity pressures did not ease and it was not until 10.45 pm when she entered hospital. She was then reviewed by a doctor, a blood test performed and it was ascertained Janet was in septic shock and by 00.26 hours her condition was regarded as likely to prove non - survivable. Janet died at 00.42 hours on 27th January 2026. A post mortem examination confirmed Janet had pneumonia which had caused an overwhelming sepsis response and multi - organ failure which proved fatal. From the available evidence, by the time she arrived at hospital, Janet was very unwell and likely to die even if she had received a timely clinical assessment and necessary treatment including antibiotics. In the absence of such treatment, from approximately 7.30 pm that evening, any subsequent treatment would not have altered the outcome.

In box 4 of the Record of Inquest I determined the conclusion to be one of:

Natural causes

Circumstances of the death

In addition to the contents of section 3 above, the following is of note:

 Janet Springall had a learning disability, was immunosuppressed and at increased risk of infection, and due to pressures on the emergency department had to remain for many hours in the ambulance outside of the hospital. Paramedics, aware she was at serious risk of a life-threatening infection and required urgent treatment, raised their concerns but it was not possible to offload Janet from the ambulance for almost six hours after arrival.  During the inquest, I was told as follows:

 In the past, in the event a patient had to remain on the ambulance outside hospital, it was possible for clinical / nursing staff to leave the hospital to provide some treatment on the ambulance;  This no longer happens, and the court was informed this follows guidance from the Care Quality Commission [the CQC were not an Interested Person for this inquest]  An experienced Clinical Matron provided helpful evidence to the court, and she explained how in terms of available resources, should nursing staff exit the hospital to conduct a blood test, for example, in an ambulance outside of the department this requires two members of staff to exit the emergency department which may leave often very unwell patients without urgent medical attention.  In Janet’s case, an overwhelming sepsis response could not be confirmed until after midnight when blood test results were available. Had it been possible for hospital staff to access the ambulance to conduct a blood test earlier that day, once the results of that test were available, the administration of intravenous fluids and antibiotics may have mitigated the risk to her life.  Janet was clearly very unwell upon arrival at hospital, and I found that by the time she entered hospital, it became clear she would die. I also found that by around 7.30 pm that evening, any subsequent treatment would not have altered the outcome.  In the absence of urgent clinical assessment by hospital staff, the witnesses from the North West Ambulance Service, including the Paramedic who had been with Janet in the ambulance, explained how the focus of her care was on trying to ensure her condition remained stable and she did not deteriorate whilst before she could enter the department.  Triage consisted of a discussion between the paramedic and the triage nurse inside of the department, and not in Janet’s presence, at shortly before 5 pm that day. It would have been clear to the triaging nurse that such were the exceptional pressures on the day it was likely Janet would be able to enter the department for many hours.  An independent expert witness told the court how in his experience, there are circumstances in which the concerns for a patient are such that clinical staff will access the ambulance. This did not appear to be the position at hospital trusts in Blackpool.  There is no doubt that on the day Janet went to hospital, the emergency department was experiencing exceptionally high patient numbers, and significantly higher than other similarly departments in the other hospitals in the region on that day.  Blackpool Teaching Hospitals NHS Trust had conducted an internal review, and having considered that document, and having listened to evidence at the inquest, it appeared to me the Trust has made significant changes since Janet died with a view to minimising the number of patients who may have to wait on ambulances outside of hospital. This is to be welcomed.

Having considered all of the above, I have determined that I have a duty to write this report.

Copies sent to

North West Ambulance ServiceBlackpool Teaching Hospitals NHS Foundation Trust

Inquest conclusion

Janet Springall was aged 68 years. She had a learning disability and her medical history included previously diagnosed rheumatoid arthritis for which she was treated with immunosuppressant medication, placing her at increased risk of developing infection. After a period of six weeks in hospital, she was discharged to a care home on 10th January 2025 where she was visited regularly by her Sister. She could be reluctant to accept food and fluids. From approximately late afternoon on Thursday 23rd January 2025 she ate very little and ingested minimal fluids. On Sunday 26th January 2025 at shortly before 1.30 pm her Sister arrived to visit Janet and found her unresponsive but breathing. It is reported that a carer had seen Janet around fifteen minutes earlier, when Janet had rejected her medication but otherwise raised no concerns. From the available evidence, it cannot be stablished exactly when her condition began to deteriorate, but the deterioration had not been fully appreciated, thereby reducing the chances of Janet making a full recovery. An ambulance was requested and upon arrival, a paramedic found Janet unresponsive and hypoglycaemic. With medical assistance including intravenous glucose, she revived and was transferred to the local accident & emergency department where she was triaged at 16.58 hours that afternoon. Due to the very high number of patients in the department that day, many including Janet had to remain on ambulances. Over subsequent hours, her condition remained concerning and on occasions a paramedic sought to escalate her care with hospital staff but capacity pressures did not ease and it was not until 10.45 pm when she entered hospital. She was then reviewed by a doctor, a blood test performed and it was ascertained Janet was in septic shock and by 00.26 hours her condition was regarded as likely to prove non - survivable. Janet died at 00.42 hours on 27th January 2026. A post mortem examination confirmed Janet had pneumonia which had caused an overwhelming sepsis response and multi - organ failure which proved fatal. From the available evidence, by the time she arrived at hospital, Janet was very unwell and likely to die even if she had received a timely clinical assessment and necessary treatment including antibiotics. In the absence of such treatment, from approximately 7.30 pm that evening, any subsequent treatment would not have altered the outcome.

In box 4 of the Record of Inquest I determined the conclusion to be one of:

Natural causes

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