Record keeping fails, missed obs and no escalation led to killer going unfound at Blackpool Victoria Hospital

This week coroner Alan Wilson sitting at Blackpool Town Hall has probed the circumstances that led to the death of beloved mother, grandmother and aunt Valerie Kneale.

75-year-old Mrs Kneale died four days after being admitted on the stroke unit at Blackpool Vic in November 2018 after suffering a stroke at her home in Poulton.

The coroner confirmed that while the ward should have been secure, police investigations found doors were at times left open or entry gained by tailgating.

Mr Wilson acknowledged the challenges of witness recollection over the seven years since Mrs Kneale’s death but said the medical and forensic evidence was clear.

He ruled that the retired clerical assistant died as a result of “unlawful act manslaughter,” caused by a sexual assault while she was a patient on the stroke unit.

He said: “This was a horrific and extreme act carried out against a vulnerable woman. It is not possible to identify who inflicted the injury, but what is certain is that Mrs Kneale died from a vile sexual assault. Her death was an unlawful killing.

“I can conclude that Valerie Kneale died of unlawful killing unlawful act manslaughter.”

Mr Wilson added that record-keeping failures, missed observations and a lack of escalation by hospital staff had compromised the investigation.

He also paid tribute to Mrs Kneale’s family, many of whom attended the inquest throughout.

He said: “It is a real testament to her that you have been here in such numbers. This has been one of the most difficult inquests a family has had to face in recent years.”

A witness reported Mrs Kneale suffered heavy blood loss that soaked through the bedsheets and mattress, requiring a body bag before transfer to the mortuary.

The court heard the request for a body bag was unusual and that healthcare assistant David Henderson unintentionally downplayed the situation at the time. It was also noted there was a strong, unusual smell in Mrs Kneale’s room, but the incident was neither documented nor escalated to senior staff.

Mr Wilson said: “I was not convinced by the accounts given by HCA’s David Henderson and Victoria Holhouse. Their evidence was weak, and I believe they were present when the bleeding occurred but did not know how to act.

“Henderson appeared to remove the catheter himself, but I preferred Langley’s version of events.

“The request for a body bag was unusual and downplayed. This incident was serious and should have been escalated to senior staff, police, or the coroner.

“Sister Tracy Brown, who was nearby also failed to respond appropriately and her dismissive approach did not reflect well on the Trust.

“These shortcomings meant vital evidence was lost, preventing a full investigation.”

Mrs Kneale’s family recalled that on the evening of November 12, 2018 she had been talkative, coherent and calm after being admitted to hospital.

However, the next morning they were told her condition had worsened significantly. They remained by her side from then until her death, although none of them was present during the early hours of November 13.

A post-mortem later determined that Mrs Kneale had not died as a result of her stroke but from injuries caused by a “violent sexual assault” that took place while she was in hospital at least 48 hours before her death.

This finding made by forensic pathologist Dr Alison Armour, led to a murder investigation. Police had already been alerted that month to allegations of neglect and mistreatment on the hospital’s stroke ward.

Nurse Matthew Pover, who was leading the ward during the overnight shift on November 12-13 told police he had not noticed any signs of injury when he cared for Mrs Kneale.

At the time a Band 5 nurse, Mr Pover said there was “no clinical reason” for him to examine her vaginal area.

He said: “I cannot believe Valerie suffered this injury on my ward,” he told investigators adding that family members had been with her constantly leaving little opportunity for such an assault to occur.

Coroner Alan Wilson asked him during the hearing if that was still his position. Mr Pover confirmed: “That was my expression of utter disbelief. I just can’t believe this happened to Mrs Kneale.”

Although the stroke ward was supposed to be secure police found that the entry doors were sometimes left propped open or staff allowed others to follow them inside. Mr Pover said such lapses were less likely overnight when the hospital was quieter.

He recalled that Mrs Kneale was lucid and able to communicate upon her arrival and that he helped move her from a side room to Ward 32 reserved for female stroke patients.

However, he did not recall seeing her again that shift. He relied on his colleague in charge of the bay to monitor her and raise any concerns, none were reported.

On November 16, 2018 when healthcare assistants were preparing Mrs Kneale’s body for the mortuary, they discovered heavy bleeding, particularly in the vaginal area. Despite this, no alarm was raised at the time.

One assistant told Mr Pover about the blood, but he reportedly replied that it was “not unusual” for a body to release fluids after death.

At the inquest, he admitted he had not grasped the seriousness of the situation, saying, “I don’t think I computed it as blood.”

When questioned by the family’s solicitor about why he had not documented the bleeding, he explained he was not responsible for Mrs Kneale’s care that day as he was on the ward only for training.

Earlier this week, retired detective chief inspector Jill Riley testified that the failure to act on the discovery of blood caused a “significant delay” in preserving evidence.

By the time the post-mortem findings were received in December, Mrs Kneale’s room had been cleaned, her clothing disposed of and CCTV footage overwritten.

Police had already launched an investigation in November 2018 after a student nurse raised concerns about patient care on the stroke unit.

As part of this inquiry, Mrs Kneale’s body was retrieved from a funeral home for a post-mortem on December 4.

A murder investigation followed, but despite extensive efforts no suspect was ever identified.

Appeals for information, including a £20,000 reward from Crimestoppers were issued in local and national media, but no further leads emerged and the investigation was closed. Lancashire Police worked with BBC Crimewatch in a bid to catch the culprit, with the programme featuring a reconstruction of the circumstances around Valerie’s death as well as interviews with Valerie’s niece as her family continue to seek justice for the murdered mum.

Separately, in December 2023 two healthcare workers were jailed for unlawfully sedating patients on the stroke unit and boasting about it in text messages.

Three other former staff, including Mr Pover admitted offences linked to the sedation scandal.

Mr Pover received a suspended 24-week sentence with community service and rehabilitation requirements for theft and supplying the sleeping pill Zopiclone. His conviction was not raised during the inquest.

Both the Acute Stroke Ward and the Continuing Care Unit at Blackpool Hospital are rated as inadequate or requiring improvement under the current Trust ratings.