Health Minister Karin Smyth says a busy Blackpool Vic A&E 'missed opportunities' on day woman, 68, died

A number of "missed opportunities" contributed to the death of a woman left waiting in an ambulance outside Blackpool Vic for nearly six hours.

And a Department of Health report has revealed the tragedy occurred while the hospital was under such pressure that patient safety could not be guaranteed.

68-year-old Janet Springall was fighting for her life when she was blue-lighted to the hospital after her sister found her unconscious at a care home.

Janet, who had learning difficulties was discharged to the carer home after spending six weeks in hospital at the beginning of 2025 and had only been there a few days.

She was reluctant to accept food and drink and on the day of her collapse had eaten "very little and ingested minimal fluids".

Paramedics found she was hypoglycaemic and she was revived with some glucose.

She was taken to Blackpool Victoria Hospital's A&E at 4.58pm on January 26. But, due to the "very high number of patients in the department that day", she was left waiting in the ambulance for more than five hours.

Despite pleas from paramedics about her worsening condition, Janet could not be admitted to the hospital.

She was eventually seen by a doctor at 10.45pm who found she was in septic shock.

Her condition was "unsurvivable" and she died at 12.42am the following day.

A post mortem found Janet had pneumonia which had caused sepsis and multi-organ failure.

Blackpool coroner Alan Wilson said that although improvements had been made at the hospital, he believed patients were still "at risk".

This week, Minister of State for Health, Karin Smyth, revealed the findings of an investigation into why Janet had been left in the ambulance for such a long time.

She said: " The report raises concerns over the continued pressure experienced in the emergency department in Blackpool Teaching Hospital NHS Trust causing patients to remain in ambulances despite needing immediate care within the department.

"The investigation highlighted Ms Springall’s attendance at the emergency department via ambulance transfer during a period of extreme pressure and ambulance handover escalation protocols should have been activated.

"Investigation findings noted that although Ms Springall presented with significant risk factors, the triage assessment was inaccurate, did not acknowledge her recent admission, and did not consider sepsis despite Trust guidance requiring this on presentation."

The minister said that on the day of Janet's admission, the A&E was operating at OPEL 4 level.

OPEL 4 (Operational Pressures Escalation Level) is the highest tier of NHS emergency alert meaning the hospital is under extreme strain and patient safety is at risk.

Mrs Smyth highlighted opportunities missed by the hospital:

- Sepsis screening was not completed.

- Janet's case was not escalated to a "senior decision maker.

- There was no clear "patient ownership" as she waited for a bed in A&E.

- Triage was not carried out properly.

- Significant delays in assessment and treatment occurred.

Following the health department investigation, which also included the North West Ambulance Service, emergency staff at the Vic have been given extra training in how to spot the sepsis.

And a maximum ambulance wait time of 45 minutes has been implemented at the hospital.

Coroner Mr Wilson said: "Janet had a learning disability, was immunosuppressed and at increased risk of infection and due to pressures on the emergency department had to remain for many hours in the ambulance outside of the hospital.

"Paramedics, aware she was at serious risk of a life-threatening infection and required urgent treatment, raised their concerns but it was not possible to offload Janet from the ambulance for almost six hours after arrival."

He added, in his report which was also sent to the Care Quality Commission as well as the Department for Health and Social Care: "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."

Last month, The Gazette reported that the number of people waiting 12 hours at A&E at the Vic had been cut by 43 per cent to reduce "corridor care".

A spokesman for Blackpool Victoria Hospital has been approached for comment.