'Risk of future deaths' - Coroner's warning after dad NOT told he needed urgent care at Cleveleys GP surgery
The death of a keen hillwalker could possibly have been prevented if had been told to seek emergency hospital care when he visited his GP surgery, a coroner has concluded.
A keen hillwalker died after he was not informed he needed to seek urgent hospital care during a visit to his GP surgery.
65-year-old Martin Ormond from Cleveleys died on January 25, 2025 in Blackpool Victoria Hospital just two days after visiting his GP surgery The Crescent based at Cleveleys Health Centre in Kelso Avenue concerned he had a chest infestion.
The retired finance director had undergone an ECG (Electrocardiogram) at the surgery on January 23, 2025.
But Senior coroner for Blackpool and Fylde Alan Wilson has raised concerns in a prevention of future deaths report about the way the results were processed after Mr Ormond was not told he needed to seek urgent medical attention at hospital.
During an inquest into Mr Ormond’s death in February, the coroner heard that the Nurse Practitioner forwarded the ECG trace as protocol to an external company - Broomwell HealthWatch Ltd – who were to interpret the results.
The ECG trace was considered, and a report sent back to the Nurse Practitioner.
Nine minutes later, a further report was also sent to the Nurse Practitioner which included some additional comments and concerns which indicated Mr Ormond needed to attend A&E urgently.
But the GP responsible for overseeing Mr Ormond’s care at The Crescent Surgey told his inquest despite evidence he had seen the ECG trace, he could not recall recall seeing either of the two subsequent reports provided by Broomwell HealthWatch.
Mr Wilson said: “The evidence of the GP was that he had seen the ECG trace, but could not recall seeing either of the two subsequent reports provided by Broomwell HealthWatch. “Neither did he recall being told verbally by the Nurse Practitioner that reference had been made to “triple vessel disease”, stating that had this been mentioned to him, he would have spoken to Mr Ormond and his wife “to advise them he needed to be reviewed in hospital for further investigations, and that he needed to go to hospital within 24 hours”.
The coroner said it transpired that Mr Ormond was not advised to go to hospital at that time, but that a cardiology referral was made which meant he would most likely have to wait a minimum of two weeks to be seen by a specialist.
Sadly, Mr Ormond had not been seen a cardiologist by the time he died two days later.
A post mortem confirmed Mr Ormond died from the effects of an acute myocardial infarction and his death was contributed to by pneumonia.
Mr Wilson said: “The Nurse Practitioner informed the court that although Broomwell Healthwatch interpret many ECG traces for the GP surgery, he could not recall a previous occasion when a second report has been sent to the surgery in order to highlight some “additional comments”.
“When the second report was sent by email to the GP surgery, notwithstanding it was sent quickly, it seemed to me feasible that medical professionals may make decisions based on the first report, and that any important additional comments may go unnoticed, thereby placing patients at risk.”
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Action should be taken
The coroner has sent his prevention of future deaths report to The Crescent GP Surgery and Broomwell HealthWatch stating “In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action”.
He told both parties they had a duty to respond to his report by the end of April 2026 with their responses containing details of action taken or proposed to be taken, as well as setting out the timetable for action.
Mr Wilson said: “During the course of the inquest, the evidence revealed matters giving rise to concern.
“In my opinion, there is a risk that future deaths could occur unless action is taken.
“In the circumstances it is my statutory duty to send the report: The matters of concern are follows: 1. At the GP surgery, a GP made decisions in the absence of the necessary information – notably two reports submitted by an external company asked to interpret an ECG trace - and it did not seem that there was an effective process in place to ensure GPs are provided with the necessary information.
“2. In the event the external company decides to submit an amended report, there appeared to be no effective process in place to ensure what may be important additional information reaches the relevant GP before important decisions are made regarding patients.
“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.”
A spokesman from The Crescent Surgery said: “Firstly we would like to offer our deepest condolences to Mr Ormond’s wife and the rest of his family. We are aware of the report from the coroner’s office, and we are working with a number of organisations in order to provide a full response outlining how we intend to address concerns raised.
“For reasons of patient confidentiality, we are unable to comment further.”
On what would have been Mr Ormond’s 66th birthday , one of his two sons Dave set off from Ambleside, walking 130 miles over six days, visiting all 16 lakes and waters and retracing many of the routes he and his father once hiked together to raise money for the British Heart Foundation.
Dave was joined by his brother James and his uncle Kevin for parts of the journey, which included climbing Old Man of Coniston, Pillar and Helvellyn.
“It was emotional at times, but I found a lot of peace along the way,” he said.
More than 26,000 people in Blackpool are currently living with cardiovascular disease.
Across the North West, the British Heart Foundation funds research projects totalling £22 million.
For more information about the work of the British Heart Foundation visit the charity’s website here.