Blackpool Teaching Hospital NHS Trust
NHS Trust
Action Taken
AI-generated response summary
The Trust has implemented an automated response for out-of-hours ECG inboxes to provide urgent escalation information. It also plans to ratify a revised Acute Coronary Syndrome pathway by September 2026, introduce new documentation standards, review staffing capacity, and conduct an options appraisal for a digital escalation solution.
View full response
Dear Mr Wilson Re: Regulation 28: Report to Prevent Future Deaths - Roland Jean Michaud On behalf of Blackpool Teaching Hospitals NHS Foundation Trust, I would like to extend my sincere condolences to the family of Roland Jean Michaud. Thank you for bringing these concerns to our attention. The Report to Prevent Future Deaths identified five concerns relating to cardiac coordinator capacity, weekend and bank holiday arrangements, record keeping, the volume of referrals managed by the regional cardiac centre, and understanding of the Acute Coronary Syndrome pathway. The Trust’s response to each concern is set out below.
1. Limited staffing within the cardiac coordinator role
2. No cardiac care coordinator cover at weekends or on bank holidays
3. Inadequate record keeping
4. The volume of cardiac patients managed by the Blackpool team
5. Limited understanding of the Acute Coronary Syndrome pathway and expected practice Trust Response Please find below the Trust’s response to the matters raised in the Report to Prevent Future Deaths. This response sets out the Trust’s position against each concern, the actions already taken, and the additional assurance arrangements being put in place to strengthen regional cardiac centre processes for patients on the Acute Coronary Syndrome pathway.
[Page 2] The Trust recognises the seriousness of the concerns raised and the importance of timely referral review, reliable escalation, clear documentation and shared understanding of the pathway. A review has been undertaken of the pathway, communication routes between district general hospitals and the regional cardiac centre, and the governance arrangements needed to monitor whether improvements are implemented and sustained. Trust Context and Immediate Learning Blackpool Victoria Hospital hosts the regional cardiac centre and receives referrals from district general hospitals for coronary angiography and other cardiac interventions. The Trust’s review identified that the pathway did not provide sufficiently clear guidance about what should happen when a patient’s symptoms changed or continued after an initial referral decision. The key learning is that any new, worsening or persistent symptoms must prompt direct clinician-to-clinician escalation to the on-call cardiology registrar or consultant, supported by clear documentation. Accepted patients awaiting transfer are reviewed and prioritised at the daily 1 pm operational meeting, with input from cardiac coordinators and the bed management team. The Trust is also undertaking an options appraisal for a longer-term digital solution to support escalation, communication and documentation. No implementation date will be confirmed until the preferred option has completed information governance, clinical safety, funding, procurement and operational approval. Cardiology bed availability has at times been affected by wider organisational pressures. Oversight of accepted patients awaiting transfer has therefore been strengthened through the daily 1pm operational meeting. Early, unvalidated monitoring suggests that clinically stable patients are generally transferring within 24 hours of acceptance; this is not yet presented as a confirmed performance position. A defined audit will validate the baseline, examine weekday, out-of-hours, weekend and bank holiday performance, and identify any delays requiring escalation. The key learning is that a change in a patient’s condition must prompt direct clinical re-escalation, irrespective of the initial referral decision or the availability of a cardiac coordinator. The revised pathway will make this requirement explicit, including arrangements for weekends, bank holidays and out-of-hours periods. Ratification is scheduled for September 2026, followed by dissemination to district general hospitals and internal teams and delivery of education and question-and-answer sessions during October 2026. Response to the specific concerns raised Coroner Trust response and assurance concern Limited The cardiac coordinator team is fully staffed to its current establishment; staffing within however, this does not in itself demonstrate that capacity is sufficient for the cardiac demand. Cardiology governance will review referral volumes, response times, coordinator transfer delays, workload and out-of-hours activity to determine whether the role establishment and operating model remain appropriate. The outcome, any required action and an agreed completion date will be reported through divisional quality and safety governance. No cardiac The cardiac coordinator role supports routine referral management and transfer care coordination. Urgent deterioration, persistent chest pain or any new clinical coordinator concern must be escalated directly to the on-call cardiology team through cover at clinician-to-clinician discussion. The revised pathway will state this explicitly. weekends or Weekend and bank holiday referral and transfer times will be included in the planned audit to determine whether the absence of coordinator cover contributes
[Page 3] on bank to delay. Cardiac coordinators will continue to provide the bed management holidays team each Friday with details of accepted patients awaiting transfer. Inadequate The Trust recognises the need for an accurate chronological record of inter- record keeping hospital discussions, advice and escalation decisions. A minimum documentation standard will record the clinical question, advice provided, escalation decision, responsible clinicians and transfer plan. An interim Microsoft Teams arrangement for recording inter-hospital discussion is proposed from September 2026, subject to confirmation of information governance and clinical safety approval. Where used, relevant information must also be entered into the patient’s clinical record in accordance with the agreed process. A longer-term electronic referral or handover solution remains subject to options appraisal and formal approval. Volume of The Trust will review demand and capacity across weekday, out-of-hours, cardiac weekend and bank holiday referrals, including response times, transfer delays, patients bed availability and workload. Current activity is approximately 100–126 Acute managed by Coronary Syndrome pathway referrals each month. The review will establish a the Blackpool validated baseline, identify any capacity or process gap, and set out any further team action required. Limited The revised pathway will clarify the appropriate use of email, urgent escalation understanding triggers, out-of-hours arrangements and the requirement for direct clinician-to- of the Acute clinician discussion when a patient’s condition changes. Following ratification in Coronary September 2026, the pathway will be shared with district general hospitals and Syndrome internal teams. Education and question-and-answer sessions are planned for pathway and October 2026, with understanding tested through realistic referral scenarios and expected subsequent audit. practice The Trust has taken, and is continuing to take, a series of actions to strengthen the Acute Coronary Syndrome referral and escalation process. The actions are summarised below. Action Theme Issue identified Action Lead role Timescale / no. status 27711 Policy shared Referral process Re-share Cardiology Start: with staff and awareness CARD/GUID/017 operational 30/04/2026. partner following the out-of-Lancashire Cardiac lead Target: organisations hours sharing of Centre Cardiac Chest 31/10/2026. follow-up Pain Pathway and Status: electrocardiograms, CORP/PROC/580 awaiting where there was no Regional Primary ratification evidence that a Percutaneous Intervention prior to re- discussion took for Acute ST Elevation sharing with place with the on- Myocardial Infarction district call registrar to documents with district general expedite review. general hospitals to hospitals and improve awareness and relevant staff. knowledge.
[Page 4] 27723 Review of Electrocardiograms Automated response Cardiology Completed: process, policy sent to an inbox out added to the receiving operational 05/05/2026. and pathway of hours were not inbox advising of lead being promptly escalation information and reviewed. contact details where urgent support is required. 27724 Review of The regional Review and update Cardiology Start: process, policy pathway required CORP/PROC/580 to operational 01/05/2026. and pathway clearer guidance provide clear guidance to lead Original on the use of email district general hospitals target: when sharing test on email use for 31/07/2026. or scan reports, investigation reports and Revised and on escalation to reinforce that urgent target: to the on-call cases must be alerted to September registrar. the on-call registrar in a 2026. Status: timely manner. the original target was not met; the updated policy is in peer review with Cardiology Consultants before ratification and subsequent dissemination. 27761 Documentation Need to improve Subject to information Cardiology Start: and record documentation and governance and clinical governance 07/05/2026. keeping capture of safety approval, introduce lead Original conversations an interim Microsoft target: between district Teams arrangement for 21/08/2026. general hospitals registrars to record Revised and the regional conversations with district target: cardiac centre. general hospitals. The September agreed process will 2026, subject require clinically relevant to information information to be governance transferred into the and clinical patient’s clinical record. safety Compliance will be tested approval. through documentation Status: interim audit. process under approval; longer-term options are being assessed with
[Page 5] BTH informatics and external suppliers. 28124 Digital Opportunity to Complete an options Cardiology Start: escalation strengthen appraisal of Alertive, operational 23/06/2026. support escalation and Patient Pass or an lead Options communication equivalent solution to appraisal reliability through support timely escalation, target: digital support. communication and 31/08/2026. documentation. The Status: preferred option will be appraisal in subject to information progress. A governance, clinical delivery date safety, funding, will be procurement and confirmed operational approval only after the before an implementation preferred plan and date are agreed. option has received all required approvals. Strengthening oversight and assurance Cardiology governance will maintain a single action plan covering the concerns, with a named lead, target date, evidence of completion and effectiveness measure for each action. Monthly monitoring will review referral response times, accepted-to-transfer times, weekend and bank holiday performance, urgent clinician-to-clinician escalation, documentation completeness, related incidents and demand against coordinator capacity. Baselines and performance thresholds will be agreed following the initial audit; exceptions and overdue actions will be escalated through divisional quality and safety governance. A quarterly compliance report will summarise performance, action status, audit findings, feedback from referring district general hospitals and the outcome of scenario testing. The report will be reviewed by the divisional quality and safety meeting, with material concerns escalated to the appropriate executive governance forum. A formal effectiveness review will be completed after implementation of the revised pathway and associated education, and actions will remain open until completion and sustained improvement are evidenced. Conclusion I hope this response provides assurance that the Trust has taken the matters raised seriously and has identified actions to address the concerns. The Trust will continue to maintain oversight of these actions until they are completed, embedded and supported by evidence of sustained improvement. If any further information is required, please let me know.
1. Limited staffing within the cardiac coordinator role
2. No cardiac care coordinator cover at weekends or on bank holidays
3. Inadequate record keeping
4. The volume of cardiac patients managed by the Blackpool team
5. Limited understanding of the Acute Coronary Syndrome pathway and expected practice Trust Response Please find below the Trust’s response to the matters raised in the Report to Prevent Future Deaths. This response sets out the Trust’s position against each concern, the actions already taken, and the additional assurance arrangements being put in place to strengthen regional cardiac centre processes for patients on the Acute Coronary Syndrome pathway.
[Page 2] The Trust recognises the seriousness of the concerns raised and the importance of timely referral review, reliable escalation, clear documentation and shared understanding of the pathway. A review has been undertaken of the pathway, communication routes between district general hospitals and the regional cardiac centre, and the governance arrangements needed to monitor whether improvements are implemented and sustained. Trust Context and Immediate Learning Blackpool Victoria Hospital hosts the regional cardiac centre and receives referrals from district general hospitals for coronary angiography and other cardiac interventions. The Trust’s review identified that the pathway did not provide sufficiently clear guidance about what should happen when a patient’s symptoms changed or continued after an initial referral decision. The key learning is that any new, worsening or persistent symptoms must prompt direct clinician-to-clinician escalation to the on-call cardiology registrar or consultant, supported by clear documentation. Accepted patients awaiting transfer are reviewed and prioritised at the daily 1 pm operational meeting, with input from cardiac coordinators and the bed management team. The Trust is also undertaking an options appraisal for a longer-term digital solution to support escalation, communication and documentation. No implementation date will be confirmed until the preferred option has completed information governance, clinical safety, funding, procurement and operational approval. Cardiology bed availability has at times been affected by wider organisational pressures. Oversight of accepted patients awaiting transfer has therefore been strengthened through the daily 1pm operational meeting. Early, unvalidated monitoring suggests that clinically stable patients are generally transferring within 24 hours of acceptance; this is not yet presented as a confirmed performance position. A defined audit will validate the baseline, examine weekday, out-of-hours, weekend and bank holiday performance, and identify any delays requiring escalation. The key learning is that a change in a patient’s condition must prompt direct clinical re-escalation, irrespective of the initial referral decision or the availability of a cardiac coordinator. The revised pathway will make this requirement explicit, including arrangements for weekends, bank holidays and out-of-hours periods. Ratification is scheduled for September 2026, followed by dissemination to district general hospitals and internal teams and delivery of education and question-and-answer sessions during October 2026. Response to the specific concerns raised Coroner Trust response and assurance concern Limited The cardiac coordinator team is fully staffed to its current establishment; staffing within however, this does not in itself demonstrate that capacity is sufficient for the cardiac demand. Cardiology governance will review referral volumes, response times, coordinator transfer delays, workload and out-of-hours activity to determine whether the role establishment and operating model remain appropriate. The outcome, any required action and an agreed completion date will be reported through divisional quality and safety governance. No cardiac The cardiac coordinator role supports routine referral management and transfer care coordination. Urgent deterioration, persistent chest pain or any new clinical coordinator concern must be escalated directly to the on-call cardiology team through cover at clinician-to-clinician discussion. The revised pathway will state this explicitly. weekends or Weekend and bank holiday referral and transfer times will be included in the planned audit to determine whether the absence of coordinator cover contributes
[Page 3] on bank to delay. Cardiac coordinators will continue to provide the bed management holidays team each Friday with details of accepted patients awaiting transfer. Inadequate The Trust recognises the need for an accurate chronological record of inter- record keeping hospital discussions, advice and escalation decisions. A minimum documentation standard will record the clinical question, advice provided, escalation decision, responsible clinicians and transfer plan. An interim Microsoft Teams arrangement for recording inter-hospital discussion is proposed from September 2026, subject to confirmation of information governance and clinical safety approval. Where used, relevant information must also be entered into the patient’s clinical record in accordance with the agreed process. A longer-term electronic referral or handover solution remains subject to options appraisal and formal approval. Volume of The Trust will review demand and capacity across weekday, out-of-hours, cardiac weekend and bank holiday referrals, including response times, transfer delays, patients bed availability and workload. Current activity is approximately 100–126 Acute managed by Coronary Syndrome pathway referrals each month. The review will establish a the Blackpool validated baseline, identify any capacity or process gap, and set out any further team action required. Limited The revised pathway will clarify the appropriate use of email, urgent escalation understanding triggers, out-of-hours arrangements and the requirement for direct clinician-to- of the Acute clinician discussion when a patient’s condition changes. Following ratification in Coronary September 2026, the pathway will be shared with district general hospitals and Syndrome internal teams. Education and question-and-answer sessions are planned for pathway and October 2026, with understanding tested through realistic referral scenarios and expected subsequent audit. practice The Trust has taken, and is continuing to take, a series of actions to strengthen the Acute Coronary Syndrome referral and escalation process. The actions are summarised below. Action Theme Issue identified Action Lead role Timescale / no. status 27711 Policy shared Referral process Re-share Cardiology Start: with staff and awareness CARD/GUID/017 operational 30/04/2026. partner following the out-of-Lancashire Cardiac lead Target: organisations hours sharing of Centre Cardiac Chest 31/10/2026. follow-up Pain Pathway and Status: electrocardiograms, CORP/PROC/580 awaiting where there was no Regional Primary ratification evidence that a Percutaneous Intervention prior to re- discussion took for Acute ST Elevation sharing with place with the on- Myocardial Infarction district call registrar to documents with district general expedite review. general hospitals to hospitals and improve awareness and relevant staff. knowledge.
[Page 4] 27723 Review of Electrocardiograms Automated response Cardiology Completed: process, policy sent to an inbox out added to the receiving operational 05/05/2026. and pathway of hours were not inbox advising of lead being promptly escalation information and reviewed. contact details where urgent support is required. 27724 Review of The regional Review and update Cardiology Start: process, policy pathway required CORP/PROC/580 to operational 01/05/2026. and pathway clearer guidance provide clear guidance to lead Original on the use of email district general hospitals target: when sharing test on email use for 31/07/2026. or scan reports, investigation reports and Revised and on escalation to reinforce that urgent target: to the on-call cases must be alerted to September registrar. the on-call registrar in a 2026. Status: timely manner. the original target was not met; the updated policy is in peer review with Cardiology Consultants before ratification and subsequent dissemination. 27761 Documentation Need to improve Subject to information Cardiology Start: and record documentation and governance and clinical governance 07/05/2026. keeping capture of safety approval, introduce lead Original conversations an interim Microsoft target: between district Teams arrangement for 21/08/2026. general hospitals registrars to record Revised and the regional conversations with district target: cardiac centre. general hospitals. The September agreed process will 2026, subject require clinically relevant to information information to be governance transferred into the and clinical patient’s clinical record. safety Compliance will be tested approval. through documentation Status: interim audit. process under approval; longer-term options are being assessed with
[Page 5] BTH informatics and external suppliers. 28124 Digital Opportunity to Complete an options Cardiology Start: escalation strengthen appraisal of Alertive, operational 23/06/2026. support escalation and Patient Pass or an lead Options communication equivalent solution to appraisal reliability through support timely escalation, target: digital support. communication and 31/08/2026. documentation. The Status: preferred option will be appraisal in subject to information progress. A governance, clinical delivery date safety, funding, will be procurement and confirmed operational approval only after the before an implementation preferred plan and date are agreed. option has received all required approvals. Strengthening oversight and assurance Cardiology governance will maintain a single action plan covering the concerns, with a named lead, target date, evidence of completion and effectiveness measure for each action. Monthly monitoring will review referral response times, accepted-to-transfer times, weekend and bank holiday performance, urgent clinician-to-clinician escalation, documentation completeness, related incidents and demand against coordinator capacity. Baselines and performance thresholds will be agreed following the initial audit; exceptions and overdue actions will be escalated through divisional quality and safety governance. A quarterly compliance report will summarise performance, action status, audit findings, feedback from referring district general hospitals and the outcome of scenario testing. The report will be reviewed by the divisional quality and safety meeting, with material concerns escalated to the appropriate executive governance forum. A formal effectiveness review will be completed after implementation of the revised pathway and associated education, and actions will remain open until completion and sustained improvement are evidenced. Conclusion I hope this response provides assurance that the Trust has taken the matters raised seriously and has identified actions to address the concerns. The Trust will continue to maintain oversight of these actions until they are completed, embedded and supported by evidence of sustained improvement. If any further information is required, please let me know.