North Yorkshire and York
Coroner Area
Reports: 34
Earliest: Dec 2013
Latest: 11 Mar 2026
68% response rate (above 62% average).
Kenneth Swift
All Responded
2017-0331
26 Jul 2017
York Teaching Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
An elderly patient at high risk of falls was not provided with an essential falls sensor due to equipment shortages and a long waiting list, despite the known risks.
Joseph De Pellergrino-Farrugia
Partially Responded
2017-0430
3 Jul 2017
A.J Way & Co Ltd
National Trading Standards
Yorkshire Care Equipment
Other related deaths
Concerns summary
The absence of safety sensors on a chair mechanism led to a crushing injury, as it failed to detect a foot's presence and prevent operation.
Thomas Wallace
Historic (No Identified Response)
2016-0463
22 Dec 2016
North Yorkshire County Council Highways…
Road (Highways Safety) related deaths
Concerns summary
The junction has an extremely restricted view of traffic due to its layout and a solid wall. Furthermore, signage is limited and confusing, with speed limit signs visible too early.
Samuel Carroll
All Responded
2016-0384
27 Oct 2016
North Yorkshire Police
Yorkshire Ambulance Service NHS Trust
Suicide (from 2015)
Concerns summary
Police and ambulance services failed to obtain consent to inform family or friends about a patient's suicidal ideation and hospital attendance, leaving them unaware of his critical mental state.
Julie McCabe
Historic (No Identified Response)
2023-0508
4 Apr 2015
CPTA
Other related deaths
Concerns summary
The hair colourant industry's reliance on "spontaneous reports" significantly underestimates allergic reactions to PPD, creating a massive disconnect with independent research on consumer safety.
Sidney Martin
All Responded
2014-0196
1 May 2014
North West Waterways Canal & River Trust
Other related deaths
Concerns summary
The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to public safety.
Judith Marshall
All Responded
2014-0039
27 Jan 2014
NHS England
Royal Pharmaceutical Society of Great B…
Department of Health and Social Care
+1 more
Product related deaths
Concerns summary
The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory read-back procedures, and a central error database.
Action taken summary
The General Pharmaceutical Council outlines its regulatory standards and inspection processes, stating it will continue to monitor pharmacies and take action where standards are not met. They are cons
Paul Rogerson
Historic (No Identified Response)
2014-0029
22 Jan 2014
North Yorkshire Fire and Rescue Service
North Yorkshire Police
City of York Council
Community health care and emergency services related deaths
Concerns summary
River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue training, inter-agency communication, and hypothermia first aid, compounded by insufficient equipment checks.
William McCourt
All Responded
2013-0383
12 Dec 2013
Other related deaths
Concerns summary
Local residents' reports of flooding were not recorded or acted upon, and maintenance staff failed to correctly identify land ownership, leading to significant delays in addressing a safety hazard.
Action taken summary
North Yorkshire County Council has provided training to minimize human error in logging inquiries and has given clearer direction to staff for taking more detailed notes regarding site visits. Further