Lancashire health trust "deeply sorry" for failings leading to death of 71-year-old woman
“It is accepted that aspects of Mrs Ley’s care fell below the standard that she was entitled to expect, and we are deeply sorry for this.”
A 71-year-old woman with mental health issues died because of failings at Lancashire and South Cumbria NHS Foundation Trust, a coroner has claimed.
The Walton Summit-headquartered Trust has been slammed over the death of pensioner Julie Ley, with the circumstances laid out in a recently-released Prevention of Future Deaths report.
Coroner Robert Cohen also raised concerns over why a senior clinician gave CPR to Mrs Ley on a soft surface, and said he believes that future deaths will occur, unless lessons are learned from this case.
The Trust has responded, apologising for the below-standard care received by Mrs Ley, but challenging the coroner on his CPR concerns,
What happened?
According to the Report to Prevent Future Deaths (PFD report), Julie Ley had a substantial history of mental illness. In December 2024, her condition deteriorated and she became progressively more anxious and had depressive symptoms.
On several occasions Mrs Ley was admitted to hospital before being discharged to different supportive environments. However on each occasion Mrs Ley’s symptoms made it impossible for her to care for herself and she was readmitted to hospital.
On January 16, 2025, Mrs Ley was admitted to the Kentmere Ward at Westmorland General Hospital. Her condition worsened over time and she was detained under the Mental Health Act 1983 from April 7, 2025.
The coroner’s report states: “The care received by Mrs Ley on the Kentmere Ward was inadequate. From mid April 2025, Mrs Ley became increasingly withdrawn and unkempt. Insufficient support was provided to her. In May 2025 Mrs Ley stopped accepting medication, food or drink. Monitoring of Mrs Ley’s nutrition was not undertaken with appropriate diligence and she was not referred for treatment at a more appropriate hospital where IV therapy could be administered.
“The powers available under the Mental Health Act to give treatment without Mrs Ley’s consent were also not used. Mrs Ley’s physical condition deteriorated. Her risk of embolus was not properly monitored.”
“Would not have died but for these failings”
On May 15, 2025, Mrs Ley died on the Kentmere Ward, as a result of a deep vein thrombi. The report states: “Lancashire and South Cumbria NHS Foundation Trust have accepted that there were failures in respect of Mrs Ley’s nutrition, physical health monitoring, and use of legal frameworks and that Mrs Ley would not have died but for these failings.
“Mrs Ley’s death was contributed to by neglect, being the failure to monitor her nutrition, the failure to transfer her to a hospital able to treat her worsening condition and the failure to use available powers to administer medication to her.”
CPR
Mr Cohen has raised concerns that when CPR was delivered to Mrs Lay, it took place on her bed, a soft surface. When he challenged the consultant over why he hadn’t moved her to a solid surface, the consultant replied that he had attended many advanced life support training sessions and had never been told this was necessary.
Mr Cohen’s report states that a leading journal on resucitation written in 2009 notes that carrying out CPR in a hospital bed may be 50 per cent less effective and said: “I am concerned that despite receiving training a senior clinician was unaware of this and consider that it gives rise to a risk of future deaths.”
What does the Trust say?
Chris Oliver, Chief Executive of Lancashire and South Cumbria NHS Foundation Trust, has responded to the report in a letter.
It says: “On behalf of Lancashire & South Cumbria NHS Foundation Trust, I would also like to offer our sincere condolences to the family of Mrs Ley. We recognise the profound loss they have suffered and wish to reiterate our apology for the deficiencies in care identified within our internal investigation and during the course of the inquest. It is accepted that aspects of Mrs Ley’s care fell below the standard that she was entitled to expect, and we are deeply sorry for this.”
It also addresses issues raised over CPR, stating: “The Trust fully accepts the underlying principle that CPR is most effective when performed on a firm surface. However, the Trust considers it important to set out clearly the current national position, particularly as this response will be published and considered by a wider audience. Since the publication of the article cited in your report, national and international resuscitation guidance has evolved.
“Current Resuscitation Council UK guidance recognises that, although a firm surface is optimal, rescuers should not move a person from a soft surface, such as a bed, to the floor in order to commence CPR. The guidance emphasises that CPR should be started without delay on the bed and that, where required, chest compressions should be delivered with increased depth to compensate for mattress compliance, alongside the use of appropriate mitigation such as backboards.
“This guidance reflects the need to balance optimal CPR mechanics with the practical realities of in-hospital cardiac arrest, including the risks associated with manual handling and the importance of avoiding any delay in commencing life-saving treatment. The Trust’s resuscitation practice is aligned with this current national guidance.
“In response to the matters raised in your report, the Trust has nevertheless taken steps to reinforce and assure this position through resuscitation training, policy review, equipment assurance and clinical governance processes, in order to minimise the risk of misunderstanding or inconsistent practice in the future.”