Six hospital failings which must be addressed after tragedy of grandmother who bled to death

Peggy and Jim with their three daughters
Peggy and husband Jim with their three daughters -Credit:Family photo

Hospital bosses have been given a matter of days to address six failings which a coroner says put lives at risk - prior to the death of a beloved mother.

Margaret Clement from Burnley underwent a hip operation at the Royal Blackburn Hospital after falling when she was feeling sick. The mum-of-three, known as Peggy, was then transferred to Pendle Community Hospital in Nelson but began to deteriorate.

Nurses at the Reedyford ward repeatedly failed to alert doctors and recorded incorrect medication on her notes. By the time Peggy's condition was reported to doctors, she was critically unwell, and the 92-year-old died while on her way for an endoscopy after being taken back to the Royal Blackburn Hospital on June 15 in 2022.


An inquest into Peggy's death, which was held last week at Preston Coroner's Court, heard from whistle-blower Dr Fozia Shah who said she had been reporting her concerns about Pendle Community Hospital for three years before Peggy's death.

Peggy with her late husband Jim
Peggy with her late husband Jim -Credit:Family photo

Dr Shah also said that nurses had failed to alert doctors to signs of Peggy's deterioration. "There is an expectation that... it needs escalating," the doctor said. "Nobody said anything so I was completely unaware."

the doctor, who worked at Reedyford from 2019 to 2023, also revealed that she got "no answers" when she reported her concerns.

She said: "I escalated it to my seniors because I found myself in the situation where I had no choice but to raise my concerns about the vulnerability of the ward but I got no answers. I got so frustrated that I went directly to the medical director Jawad Husain. I said 'it's a huge risk'."

Area Coroner Chris Long has now sent a Prevention of Future Deaths report to East Lancashire Hospitals NHS Trust which runs Blackburn and Pendle hospitals.

The Coroners and Justice Act 2009 allows a coroner to issue a Regulation 28 Prevention of Future Deaths (PFD) Report to an individual or organisation where the coroner believes that action should be taken to prevent further deaths.

Mr Long listed six issues which the trust has 56 days to respond to and detail how they will be addressed. They are:

  1. Evidence was heard that nursing records on Reedyford were inadequate in a number of respects including recording the wrong medication, requesting a medical review for the wrong patient and not recording when an urgent review was needed in the doctor's task book.

  2. Evidence was heard that nursing handovers were inadequate and did not ensure appropriate risks were managed and prioritised.

  3. Evidence was heard that doctors on the ward did not effectively prioritise work by reviewing the task book in order to identify more urgent tasks.

  4. Nursing staff failed to request a medical review verbally when it was appropriate to do so, relying on a task book.

  5. Nursing staff failed to seek urgent clinical assistance when presented with a significant per rectal bleed.

  6. Inadequate measures have been taken to assess compliance with procedural changes and expectations that have been set following the trust's investigation into this matter.