West Yorkshire (Eastern)

Coroner Area
Reports: 122 Earliest: Aug 2013 Latest: 13 Feb 2026

75% response rate (above 63% average).

Response Status
Responded 92 Historic 30
AI Classification
Action Taken 32%
Action Planned 35%
Noted 29%
Disputed 3%
Based on 143 classified responses
Top Categories
Hospital Death (Clinical Procedure… (42) Other related deaths (22) Child Death (from 2015) (17) State Custody related deaths (16) Suicide (from 2015) (16)
Quarterly Trend
Category Breakdown
How does this area compare?
vs Yorkshire and the Humber average: +62 reports · +13pp response rate
vs national average: +38 reports · +12pp response rate
122 results
Theresa Button
All Responded
2018-0333 3 Oct 2018
Leeds Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient patient support during mealtimes, and failures in maintaining contemporaneous records.
Action Taken (AI summary) The Trust reviews staffing levels daily and has a ward/department Healthcheck audit process. Nutrition and hydration standards were addressed with the ward team and the acting ward manager attends morning handovers weekly.
Joshua Edwards
All Responded
2018-0335 2 Oct 2018
Leeds City Council
Alcohol, drug and medication related deaths Other related deaths
Concerns summary (AI summary) Ambulance response was delayed by public event road closures and unclear authority for crews to cross them. Event organizers need to brief staff and public on emergency vehicle priority.
Action Taken (AI summary) Following a previous incident, the Ambulance Service implemented learning points, including education for staff. The council hosts a joint emergency services/council Safety Advisory Group and has discussed the events of May 2017 at length.
Scott Carton
Historic (No Identified Response)
2018-0287 7 Sep 2018
MOJ National Probation Service
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without specialist input, compromises rehabilitation and increases re-offending risk.
Michael Drewell
All Responded
2018-0259 30 Aug 2018
Leeds Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A senior clinician's critical medication advice was not followed by a junior doctor, as it wasn't on electronic notes, highlighting a dangerous reliance on digital records over handwritten instructions.
Action Planned (AI summary) Leeds Teaching Hospitals NHS Trust will remind clinicians about the importance of robust handover and communication. They will also ensure individual clinicians prescribing 'off protocol' either action this themselves personally or leave clear unambiguous instructions within the electronic record.
Carol Metcalfe
All Responded
2018-0175 6 Jun 2018
Leeds City Council Highways Department
Road (Highways Safety) related deaths
Concerns summary (AI summary) Insufficient pedestrian safety measures on the A63 dual carriageway near Waterloo Manor Hospital pose a significant risk to those crossing.
Action Planned (AI summary) Following a review of pedestrian safety near Waterloo Manor Hospital, Leeds City Council will offer road safety advice and crossing training to the hospital.
Marcus Allen
All Responded
2018-0144 11 May 2018
Radcliffe Investment Properties
Other related deaths
Concerns summary (AI summary) Large lounge windows lacking restrictor devices open excessively, creating a fall hazard when residents must lean out to close them.
Action Taken (AI summary) Estates & Management has provided further training to its teams on handling correspondence. Restrictors will be installed where necessary and letters have been sent to every leaseholder to carry out a survey, and amendments made to Health and Safety Risk Assessments to undertake annual inspections of apartments to check the restrictors are functioning correctly.
Matthew Fulleylove
Historic (No Identified Response)
2018-0128 30 Apr 2018
Treanor Pujol Limited
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) Operatives have restricted space to work near metal support legs, creating a risk of fatal injuries from rotating industrial saws. Some safety measures recommended by an expert engineer have not been fully implemented for industrial machines passing on tracks 11 and 12.
Naseeb Chuhan
All Responded
2018-0099 9 Apr 2018
Financial Conduct Authority
Suicide (from 2015)
Concerns summary (AI summary) Payday loan companies contributed to the deceased's dependency by encouraging loans despite awareness, and their financial checks were inadequate.
Action Planned (AI summary) The FCA is inviting views on overdraft pricing and monitoring repeated overdraft use, aiming to consult on proposed rules by the end of 2018; they are also fostering growth of alternatives to high-cost credit and invited firms with innovative alternatives to trial their approaches.
Emily Hartley
Partially Responded
2018-0063 2 Mar 2018
Department for Health HM Prison Service
State Custody related deaths
Concerns summary (AI summary) Prison was not the appropriate environment for someone with the deceased's mental health problems, and there is a need for secure, therapeutic environments for prisoners with similar mental health needs.
Action Planned (AI summary) The Government is developing a strategy to improve outcomes for women in the community and in custody. A project is piloting to work with women who are prolific self-harers and who do not meet the criteria for other services. NHS England has developed a Ten Point Plan for Mental Health which will describe how the secure care pathway can be improved to ensure it works more effectively and efficiently.
Ann Maguire
All Responded
2017-0417 22 Nov 2017
Office for Standards in Education, Chil…
Accident at Work and Health and Safety related deaths Other related deaths
Concerns summary (AI summary) There is inconsistent management of weapon risks in schools; OFSTED should make it mandatory for inspectors to review and report on how schools prevent weapons from being brought onto premises.
Action Planned (AI summary) Ofsted will consider giving more focus to protecting pupils and staff from violent attack as part of its review of the inspection framework for education inspections which is expected to be in place for September 2019; the Safeguarding Group has been made aware of the coroner's concerns and these will be taken into account in future reviews.
Jennifer Midgley
Historic (No Identified Response)
2017-0252 6 Oct 2017
Mid Yorkshire NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The drug administration chart fails to clearly distinguish between oral and intravenous paracetamol, lacks patient weight reference for IV dosage, and omits a reminder for weight-modified administration.
Elaine Davison
Historic (No Identified Response)
2017-0444 12 Jul 2017
National Tree Safety Group
Road (Highways Safety) related deaths
Concerns summary (AI summary) A diseased tree, despite prior examination, had a hidden severe fungal decay that was missed due to inadequate inspection and misidentification of the condition, leading to an underestimation of its felling urgency.
Margaret Conway
Historic (No Identified Response)
2017-0145 3 May 2017
Mid Yorkshire NHS Trust South West Yorkshire NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Systemic separation of mental and physical health services led to challenging patient transfers and fragmented care for individuals with co-occurring serious mental and physical health problems. Closer integration and shared resources are needed.
Billy Wilson
All Responded
2017-0061 9 Mar 2017
Nursing and Midwifery Council
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical gaps exist in mandatory and assessed training for CTG tracing interpretation for both student and practicing midwives, leading to proficiency issues upon hospital recruitment.
Noted (AI summary) The Royal College of Obstetricians & Gynaecologists acknowledges the concerns regarding CTG training. They note CTG training is part of the current curriculum and offer support for further proposal.
Maxim Karpovich
All Responded
2017-0054 22 Feb 2017
Royal College of Midwives Royal College of Obstetricians and Gyna…
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Midwives and a junior obstetrician did not understand that the CTG trace was abnormal, and an obstetric registrar incorrectly classified the CTG as normal; the coroner noted that midwives and obstetricians lack the core skills to interpret CTG tracings for intrapartum care.
Noted (AI summary) The RCOG acknowledges the concerns and explains that CTG training is already part of the curriculum. They highlight existing e-learning resources and suggest a new proposal could be trialled at the RCOG. The RCM outlines the role of midwives and their responsibilities according to NMC guidelines. They reference existing resources and studies related to CTG interpretation.
Michaela Thompson
All Responded
2016-0392 2 Nov 2016
Leeds and York Partnership NHS Foundati…
Suicide (from 2015)
Concerns summary (AI summary) Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant mental health staff.
Action Planned (AI summary) The trust acknowledges the need for clear documentation of MDT meetings and recording phone calls. They propose a meeting to discuss the practicalities of recording calls before implementing a solution.
Michael Dundon
All Responded
2016-0305 23 Aug 2016
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Unsupervised liquid-absorbing crystals, mistaken for consumables, caused a patient's death. The risks of these sachets are not fully understood, necessitating improved risk assessment, staff awareness, and training.
Action Planned (AI summary) NHS Improvement is working to identify an effective method of risk reduction regarding the choking hazard of solidifying crystals used in human waste receptacles. They will consider a warning to staff, follow up with the Health and Safety Executive, and explore safer alternatives.
Thomas Jordan
Historic (No Identified Response)
10 Aug 2016
Her Majesty's Prison, Leeds The Leeds Teaching Hospitals NHS Trust
State Custody related deaths
Concerns summary (AI summary) Communication failures between the hospital and prison healthcare resulted in continued administration of a discontinued drug, as discharge information was not promptly reviewed by prison staff.
Thomas Jordan
Partially Responded
2016-0287 10 Aug 2016
Head of Healthcare, HMP Leeds Medical Director, Leeds Teaching Hospit…
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary (AI summary) Communication breakdown and failure to review discharge correspondence at the prison led to continued, incorrect drug administration after hospital clinicians requested discontinuation. Electronic discharge summaries could prevent such errors.
Action Planned (AI summary) Leeds Teaching Hospital has agreed to issue an electronic summary with all patients who transfer back to HMP Leeds following discharge. IT personnel from both the Hospital and Care UK will create a pathway to ensure all summaries are appropriately shared, and written summaries are provided in sealed envelopes in the meantime.
Angus West
All Responded
2016-0158 20 Apr 2016
York Teaching Hospitals NHS Foundation …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The placenta was not retained after a baby's death, impeding a comprehensive post-mortem examination to determine the cause, such as infection or cord issues.
Noted (AI summary) The Royal College of Midwives agrees with the coroner's recommendations to retain and safely store placentas for babies compromised in labour. They provide information regarding current practice, disposal and reasons to store placenta within the NHS. York Teaching Hospital is instituting a standard operating procedure in respect to retention of placenta following childbirth by September 2016. They have already established that all placentas are routinely inspected at all deliveries, and that all placentas from stillborn infants or intra partum deaths are sent for detailed histopathology examination.
Adam Rice
Partially Responded
2016-0085 3 Mar 2016
St James’s University Hospital West Yorkshire Police
Hospital Death (Clinical Procedures and medical management) related deaths Police related deaths
Concerns summary (AI summary) There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by inconsistent custody care, staff shortages, inadequate handovers, and a lack of understanding of welfare check protocols.
Action Taken (AI summary) West Yorkshire Police has implemented measures to ensure vulnerable persons who come into contact with the Police receive the best possible care, including a full training programme for Custody Staff on PACE and relevant provisions of the College of Policing APP. They have also implemented daily briefings for custody staff and reviewing risk assessment processes.
Max Haigh
Historic (No Identified Response)
2016-0082 1 Mar 2016
St James’s University Hospital
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate and incomplete surgical notes failed to detail a ventricular septal defect, risking future surgeons lacking vital information for subsequent operations.
Paul Whitehead
Historic (No Identified Response)
14 Dec 2015
WE Rawson Ltd, Castle Bank Mills, Porto…
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) Emergency response procedures were inefficient, with delays in contacting emergency services, inadequate first aid provision, and difficulties for paramedics locating the casualty on-site.
Irene Scholey
Historic (No Identified Response)
2015-0462 13 Nov 2015
Wakefield MDC Wakefield District Safeguarding Adults …
Other related deaths
Concerns summary (AI summary) No specific concerns were detailed in the provided text, which instead referred to an external narrative conclusion.
Neil Garry
All Responded
2015-0446-wp25121 26 Oct 2015
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI summary) A busy road frequently used by pedestrians, including children, lacks a pedestrian crossing, posing a significant safety risk.
Action Planned (AI summary) • A scheme has been designed to provide safe pedestrian assisted facilities across the Ring Road at the Ramshead Approach and Coal Road junction. • A Highways Board report is to be presented to the Chief Officer (Highways and Transportation) early in the New Year to seek formal funding approval to progress the junction improvement measures at the Ramshead Approach/ Ring Road junction. • It is currently programmed that the scheme will then be issued to contractors in this financial year, with an expected completion date onsite between May/June 2016.