City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Coroner Area
Reports: 52
Earliest: May 2014
Latest: 25 Feb 2026
81% response rate (above 62% average).
Amy Pugh
All Responded
2026-0013
1 Dec 2025
NHS England
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent management.
Action taken summary
NHS England has provided funding for EPR implementation and is actively working across the health system and with the SCR Programme to support greater integration and awareness of record sharing …
Kathleen Ward
All Responded
2025-0562
3 Nov 2025
Chief Executive – Hull Royal Infirmary
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care and risking repeat incidents due to insufficient bed capacity.
Action taken summary
Hull Royal Infirmary is strengthening escalation processes for end-of-life patients and reinforcing compassionate communication. They plan a further rollout of Comfort Observations across the organisa
Raymond Leake
All Responded
2025-0546
28 Oct 2025
Hull Royal Infirmary
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
An urgent radiology scan was missed, likely due to human error, and new preventative processes lack auditing due to staff shortages, leaving their effectiveness unconfirmed.
Action taken summary
Hull Royal Infirmary implemented new controls in March 2025 including automatic porter dispatch and direct ward contact for urgent scans. They have now completed an initial audit of CT head …
Declan Carr
All Responded
2025-0541
20 Oct 2025
NHS England
State Custody related deaths
Concerns summary
Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of care and future deaths.
Action taken summary
NHS England confirmed that a national pathway for transferring non-clinical healthcare information, including psycho-social support, between prisons was implemented on 24 November 2025. They also cond
Scott Berry
All Responded
2026-0038
20 Oct 2025
HM Prison & Probation Service
State Custody related deaths
Suicide (from 2015)
Concerns summary
Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and lack of access to parole reviews or rehabilitative programs, increasing suicide risk.
Action taken summary
HM Prison and Probation Service has implemented multiple changes to policy and practice for IPP prisoners, including revisions to release on temporary licence and offender management processes. They h
Angela Thompson
All Responded
2026-0027
7 Oct 2025
HM Prison & Probation Service
Suicide (from 2015)
Concerns summary
A lack of liaison between prison and community psychiatric services for released prisoners with ongoing mental health issues, especially when geographically distant, creates risks for continuity of care.
Action taken summary
HMPPS has established Regional Health & Justice Teams and a central Deaths Under Supervision Team to improve integrated health services and liaison for prison leavers. Learning from this case will …
Linda Sharp
All Responded
2025-0468
15 Sep 2025
President of the Royal College of Gener…
Other related deaths
Concerns summary
Relying solely on a low Wells score is a fundamentally flawed approach to exclude deep vein thrombosis or pulmonary embolus, potentially leading to missed diagnoses.
Action taken summary
The Royal College of General Practitioners acknowledges the misinterpretation of the Wells score in this case and has commissioned an e-learning module to highlight its correct interpretation. This mo
John Kirkman
All Responded
2025-0344
8 Jul 2025
NHS England
Mental Health related deaths
Suicide (from 2015)
Concerns summary
Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack of vital background information and incorrect prioritisation for referrals.
Action taken summary
NHS England highlights existing systems like the National Care Records Service (NCRS), Summary Care Record (SCR), and National Record Locator (NRL) that improve data sharing. They are also developing
Peter Ramsden
All Responded
2025-0467
8 Jul 2025
Communities and Local Government
Secretary of State for the Home Departm…
Ministry of Housing
Other related deaths
Concerns summary
A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical problem is suspected, hindering prompt, potentially life-saving treatment for incapacitated individuals.
Action taken summary
The department clarifies that Fire and Rescue Authorities (FRAs) possess statutory powers of entry under the Fire and Rescue Services Act 2004 for emergencies, including welfare checks, and that these
John Charles Spencer
All Responded
2025-0232
19 May 2025
Holderness Health – Hedon Group Practice
Care Quality Commission
Royal College of General Practitioners
+1 more
Community health care and emergency services related deaths
Concerns summary
Incompatible computer systems prevent out-of-hours GP surgeries from accessing patient medical histories, even with consent, risking vital information not being conveyed for appropriate care.
Action taken summary
NHS England is working across the health system to support greater integration and awareness of record sharing between in-hours and out-of-hours providers, and with the Shared Care Record Programme. T
Jason Myles
All Responded
2025-0087
14 Feb 2025
ERYC Highways Department
Road (Highways Safety) related deaths
Suicide (from 2015)
Concerns summary
A dangerous road known as "suicide hill" has a history of fatal collisions due to a sharp turn and topography; improved signage is needed, especially in poor visibility.
Action taken summary
The ERYC Highways Department confirms existing warning signs are in good condition and appropriate. They dispute the coroner's evidence of numerous past collisions, stating their records for the last
Eden Street
All Responded
2025-0017
10 Jan 2025
Humber Teaching NHS Foundation Trust
Child Death (from 2015)
Suicide (from 2015)
Concerns summary
Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical updates on deteriorating neurodiverse patients being missed by clinicians.
Action taken summary
Humber Teaching NHS Foundation Trust disputes the systemic issue, stating the child referenced was not on their CAMHS waiting list and their system for handling contacts is robust. However, they …
David Lodge
All Responded
2025-0041
23 Dec 2024
Care Quality Commission
Hull University Teaching Hospitals NHS …
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The emergency department failed to accurately assess pain in a non-verbal patient, conduct basic examinations for pneumonia, and appropriately escalate high NEWS2 scores, coupled with a lack of internal incident review.
Action taken summary
NHS England noted it was not directly involved in the clinical care but confirmed that a Learning Disability Mortality Review (LeDeR) is currently in progress to examine the care delivered …
Colin Wiles
All Responded
2024-0652
24 Nov 2024
East Riding of Yorkshire Council
Hull University Teaching Hospital
NHS England
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A Vulnerable Adult Risk Management meeting was not held despite high risks. Callers are not clearly advised to re-contact emergency services if concerns persist, and excessive ambulance handover delays significantly impact emergency care.
Action taken summary
NHS England states that advising callers to call back if a patient's condition deteriorates is a standard component of case exit scripts for ambulance services. They detail several existing national …
Janet Brown Townend
All Responded
2024-0595
4 Nov 2024
East Riding of Yorkshire Council
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The Safeguarding Adult Review following a patient's death was of poor quality, lacking proper investigation, documentation, and family input. This failure hinders learning and prevention of future deaths.
Action taken summary
East Riding of Yorkshire Council's Safeguarding Adults Board has decided to undertake a new Safeguarding Adult Review (SAR) for Ms Townend, which is anticipated to commence in spring 2025, in …
Geoffrey Toase and Michael Midgley
All Responded
2024-0507
12 Aug 2024
Driver and Vehicle Licensing Agency
Road (Highways Safety) related deaths
Concerns summary
DVLA's license re-issue process is flawed due to insufficient gathering of medical history from specialists and GPs, tick-box forms, and lack of verification for self-declarations. This prevents full assessment of applicants' fitness to drive.
Action taken summary
The DVLA outlined their existing processes for driver medical licensing, stating that doctors can request further information from healthcare professionals and take a holistic clinical view. They note
Raymond Brattley
All Responded
2024-0424
2 Aug 2024
Royal Society for the Prevention of Acc…
Other related deaths
Concerns summary
There are inadequate fire prevention measures for vulnerable, heavy-smoking residents in care settings. Organisations should consult the Fire Service for advice on mitigating risks, such as using metal bins and fire-retardant materials.
Action taken summary
RoSPA plans to review and update fire safety information on their website by Q4 2024, explore collaboration with the sheltered accommodation sector, and develop a policy position on fire safety …
Josh Smith
All Responded
2024-0402
15 Jul 2024
West Yorkshire Integrated Care Board
NHS England
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Persistent ambulance response delays, both for emergency calls and hospital handovers, continue to fall short of national targets, impacting timely patient care in the community.
Action taken summary
NHS England is prioritizing improving ambulance response times, reducing hospital handover delays, increasing ambulance capacity, and improving patient flow by expanding intermediate care services and
Linda Heath
All Responded
2024-0255
9 May 2024
Hull University Teaching Hospital
St Andrew’s Surgery Hull
City Healthcare Partnership Hull
+3 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Inadequate hospital discharge summaries and a lack of GP follow-up procedures for recently discharged patients led to missed referrals for critical care. There was also an over-reliance on private care with insufficient oversight.
Sylvia White
All Responded
2024-0044
30 Jan 2024
Hull University Teaching Hospitals NHS …
Other related deaths
Concerns summary
Inadequate hospital discharge summaries consistently lack crucial patient information, preventing care homes from conducting proper risk assessments and ensuring safe ongoing care.
William Helstrip
All Responded
2024-0030
19 Jan 2024
Humberside Police
Alcohol, drug and medication related deaths
Concerns summary
The initial police investigation failed to properly probe drug sourcing via the "Dark Web" and Royal Mail, leading to the irretrievable loss of critical, time-sensitive evidence.
James Holgate
All Responded
2024-0004
3 Jan 2024
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
An anomaly in the Human Tissue Act prevents body donation for medical research/training when an inquest is held, even if a post-mortem isn't needed, impeding scientific progress.
Tracey Rose
All Responded
2023-0387
17 Oct 2023
Hull and East Yorkshire NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A patient was discharged home without their anticoagulant prescription, and a hospital dose may have been missed, significantly contributing to a fatal pulmonary embolism.
Scott Donoghue
All Responded
2023-0363
28 Sep 2023
Department of Health and Social Care
Suicide (from 2015)
Concerns summary
Inconsistent staffing within Home Based Treatment Teams hinders patient engagement and honesty during fragile periods. Addressing this requires additional funding, recruitment, and retention to ensure continuity of care.
Finley May
All Responded
2023-0277
26 Jul 2023
NHS England
Royal College of Obstetricians and Gyna…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
There is a need for increased awareness of complications associated with Keilland's forceps and guidance on maintaining skill levels or providing clear alternative methods if abandoned, to manage obstetric problems.