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
Christianne Shepherd
Historic (No Identified Response)
2015-0338 18 Sep 2015
ABTA – The Travel Association Louis Group including the Louis Corcyra… The Federation of Tour Operators +4 more
Child Death (from 2015) Product related deaths
Concerns summary (AI summary) The report calls for a publicly accessible central register for tour operators to record hotel safety information, improved collaboration between tour operators regarding health and safety, increased awareness of carbon monoxide dangers, and more qualified personnel conducting health and safety checks.
Fred Hudson
Historic (No Identified Response)
2015-0188 13 May 2015
Highways England Historical Railways Estate
Other related deaths
Concerns summary (AI summary) A disused railway bridge is easily accessible to the public, including children, and no steps have been taken to prevent access despite its location next to a main road.
Maurice Camfield
Historic (No Identified Response)
2015-0176 16 Apr 2015
Mid Yorkshire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.
Connor Turner
All Responded
2015-0082 6 Mar 2015
Leeds Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was no system for training or supervising parents/carers in oxygen supply transfer, nor an independent check of apparatus function and user competence before patient discharge.
Action Taken (AI summary) Leeds Teaching Hospitals implemented a new oxygen safety passport, a checklist for patients leaving a ward with oxygen therapy, and a risk assessment for oxygen therapy, with staff training, following the death.
Alison Evers
All Responded
2015-0074 2 Mar 2015
Leeds City Council
Other related deaths
Concerns summary (AI summary) The care facility lacked a written 'no treats policy' and a policy for ensuring a first-aid-trained staff member on every shift. Furthermore, first aid training for health support workers, especially for dependent service users, was insufficient.
Action Taken (AI summary) The council has a "no treats" policy, provides first aid training, and employs staff trained in First Aid. All new staff within the Learning Disability Community Support Service receive training on Fundamental First Aid.
Lexie Harrison
Partially Responded
2015-0070 20 Feb 2015
British Society of Paediatric Gastroent… Leeds Teaching Hospitals NHS Trust NHS Improving Quality +1 more
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical lack of national and local standardised policies for paediatric oesophageal varix banding procedures leads to inconsistent consultant practices. This impacts patient assessment, post-procedure care, and bleeding management.
Noted (AI summary) The Trust shared the coroner's report with relevant staff and clarified their existing guidelines for managing bleeding oesophageal varices, including resuscitation, antibiotic use, Sengstaken tube placement, and banding procedures. They also highlighted the training provided to paediatric gastroenterology trainees in upper GI endoscopy and oesophageal varices recognition. The UHB acknowledges the coroner's concerns regarding the lack of standardized practices for paediatric endoscopy procedures, but states that they are unable to take the concerns forward themselves and suggest options that may help advance these issues.
Pauline Taylor
All Responded
2015-0008 9 Jan 2015
Department of Health and Social Care Leeds Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Ambiguity in the surgical term "nephroureterectomy" caused critical misunderstandings between clinicians regarding procedure extent. There was also an absence of a case manager to oversee complex patient care and communication.
Noted (AI summary) The Department of Health acknowledges the concerns, notes BAUS's definition of nephroureterectomy, and states that decisions on clinical team operations are for the local Trust to address, also suggesting the GMC as the appropriate body for fitness to practice concerns. The hospital clarified that "nephroureterectomy" means removal of the kidney with the whole ureter, emphasized this guidance to staff and included it in induction information. They filled Clinical Nurse Specialist posts to coordinate care for patients with possible cancer diagnoses.
Gladys Smith
Historic (No Identified Response)
2014-0502 17 Nov 2014
Berrymans Lace Mawer LLP Hempsons Solicitors Leeds City Council +6 more
Care Home Health related deaths
Concerns summary (AI summary) No specific safety concerns were detailed in the provided text.
Barry Horrocks
Historic (No Identified Response)
2014-0492 7 Nov 2014
Department of Health National Offender Management Service NHS England
State Custody related deaths
Concerns summary (AI summary) A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care provider took responsibility for vital 'social services' support.
William Anderson
Historic (No Identified Response)
2014-0452 17 Oct 2014
Solicitors Leeds Community Healthcare NHS Trust Solicitors +1 more
State Custody related deaths
Concerns summary (AI summary) Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed to adequately record inmate behaviour or promptly call emergency services.
Carol Walker
Historic (No Identified Response)
2014-0361 4 Aug 2014
Harrogate District Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospitals lacked routine chemical thrombo prophylaxis and formal risk assessment for venous thromboembolism in low-risk patients with conservatively treated lower limb injuries.
Joan Richardson
Partially Responded
2014-0276 23 Jun 2014
Fountain Medical Centre Leeds West Clinical Commissioning Group
Community health care and emergency services related deaths
Concerns summary (AI summary) The GP practice failed to provide emergency care during training closure, delaying assessment of an obviously unwell patient by 24 hours, which contributed to her death.
Action Planned (AI summary) The CCG will send a letter to all GP practices reiterating their obligations regarding safe medical cover during training sessions and emphasizing the need for clear communication regarding access to urgent medical attention. A statement will be made at a centrally organised TARGET event reiterating the obligations and recommendations.
Ann Bennett
Historic (No Identified Response)
2014-0233 9 May 2014
Leeds Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable death, necessitating a robust response.
Mary Wanya
Historic (No Identified Response)
2014-0192 30 Apr 2014
Leeds Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a flawed investigation report by unqualified staff raise serious safety concerns.
David Oldfield
All Responded
2014-0117 14 Mar 2014
West Yorkshire Police Force
State Custody related deaths
Concerns summary (AI summary) Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified tasering unnecessarily increases the risk of serious injury or death.
Noted (AI summary) West Yorkshire Police acknowledge the concerns raised, particularly regarding officer accounts, and state that the IPCC was informed. They also offer a visit to their training facilities to demonstrate Taser training and usage.
Craig Marren
All Responded
2014-0106 10 Mar 2014
Tyersal Farm
Road (Highways Safety) related deaths
Concerns summary (AI summary) Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that requires cutting back.
Action Taken (AI summary) City of Bradford Council confirms that an order has been raised for a hedge to be flailed back to clear the highway obstruction.
Ryan Clark
All Responded
2014-0057 3 Feb 2014
National Offender Management Service
Other related deaths
Concerns summary (AI summary) Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first aid and CPR training.
Action Planned (AI summary) HMP and YOI Wetherby implemented a revised personal officer scheme in October 2013 to ensure greater continuity in the allocation of staff to young people, including a 'relief' arrangement and key points for officers' roles. Leeds City Council has agreed on a procedure between Children's Social Work Service and Youth Offending Service to share all relevant information about a young person going into custody with the Young Offender Institution staff within 24 hours of arrival.
Julie Ann Camm
All Responded
2014-0023 17 Jan 2014
Leeds City Council
Mental Health related deaths
Concerns summary (AI summary) A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and increasing the risk of death from fire.
Action Planned (AI summary) Housing Leeds will install hard-wired smoke detection in 40 properties and battery-powered detectors in remaining properties without detection equipment over the next 12 months, in consultation with West Yorkshire Fire & Rescue Service. The Electrical Specification has been updated to include hard-wired detection for major electrical works, and the Annual Tenancy Visit will include smoke detection identification.
Dr Edward Slaney
Historic (No Identified Response)
2014-0030 10 Jan 2014
Ministry of Housing, Communities & Loca…
Other related deaths
Concerns summary (AI summary) There is a lack of established criteria and guidance for planning authorities to assess the wind effects of tall buildings on the safety of all highway users.
Adrian John Pickard
All Responded
2013-0358 31 Dec 2013
Lightwater Quarries Limited
Other related deaths
Concerns summary (AI summary) Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on public highways.
Disputed (AI summary) Lightwater Quarries Ltd disputes the need to weigh volumetric vehicles, arguing it's not legally required and weight wasn't a factor in the collision. They state that they would like to see such & test also introduced at the annual ministectest.
Jill Sinson
Historic (No Identified Response)
2013-0221 23 Aug 2013
Beeston Health Centre
Community health care and emergency services related deaths
Concerns summary (AI summary) The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, and staff neglected to review critical records or consultant advice.
Annie Rose Gibson
Historic (No Identified Response)
2013-0171 1 Aug 2013
Saga Homecare
Community health care and emergency services related deaths
Concerns summary (AI summary) The coroner raises concerns about a lack of clarity in Saga Homecare's procedures, specifically regarding the recording and communication of observations after a client fall.