Coroner Issues Stark Warning Following Tragic Hospital Delay Death
A senior coroner has issued a formal prevention of future deaths report after a 68-year-old woman died following a wait of more than five hours in an ambulance outside an NHS hospital. The tragic case of Janet Springall has highlighted ongoing pressures within emergency healthcare services.
Five-Hour Wait Outside Hospital
Janet Springall was rushed to Blackpool Victoria Hospital on January 26, 2025, after being found unresponsive at her care home. Paramedics discovered her hypoglycemic and administered glucose during transit, with her condition initially improving. She arrived at the hospital at 4:58pm but remained in the ambulance due to what was described as "the very high number of patients in the department that day."
It was not until 10:45pm—nearly six hours after arrival—that a doctor finally assessed Janet. Medical staff immediately recognized she was in septic shock, a life-threatening condition where the body's response to infection causes organ damage.
Medical Details and Inquest Findings
The post-mortem examination revealed Janet had developed pneumonia, which triggered an overwhelming sepsis response leading to multi-organ failure. Despite medical intervention, her condition was deemed unsurvivable, and she passed away at 00:42am on January 27.
An inquest held at Blackpool Town Hall in January 2026 concluded Janet died from natural causes. However, Senior Coroner Alan Wilson expressed significant concerns about the circumstances surrounding her death, prompting his formal prevention of future deaths report.
Coroner's Concerns About Systemic Pressures
While Coroner Wilson acknowledged that Janet was "likely to die even if she had received a timely clinical assessment and necessary treatment," he emphasized that patients remain at risk due to ongoing systemic pressures.
In his report addressed to the Care Quality Commission and the Department for Health and Social Care, Wilson stated: "The hospital 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."
The coroner noted that improvements have been implemented at the hospital since the incident but maintained that the fundamental issue of ambulance delays persists.
Background and Response Timeline
Janet Springall, who had learning difficulties, had been discharged to a care home in January 2025 after spending six weeks in hospital. She was known to be reluctant to accept food or drink, and from January 23, she had consumed minimal nourishment.
Three days later, her sister visited and found her unresponsive but breathing. A carer reported seeing Janet just 15 minutes earlier but had not fully appreciated her deterioration.
The prevention of future deaths report has been distributed to Janet's family, Blackpool Teaching Hospitals NHS Foundation Trust, and the North West Ambulance Service. Both the Care Quality Commission and the Department for Health and Social Care have 56 days to formally respond to the coroner's concerns.
This case underscores the critical challenges facing emergency healthcare services, particularly during periods of high patient demand, and raises important questions about patient safety during ambulance handover delays.
