West Yorkshire (Western)
Coroner Area
Reports: 98
Earliest: Nov 2013
Latest: 28 Oct 2025
64% response rate (above 62% average).
Philip Smith
Historic (No Identified Response)
2015-0017
21 Jan 2015
Huddersfield Royal Infirmary
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a senior medical review despite a nurse's concerns about the patient's deterioration.
Colin Ireland
Historic (No Identified Response)
2014-0493
7 Nov 2014
HMP Manchester
State Custody related deaths
Concerns summary
Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to communicate essential treatment plans to prison healthcare, compounded by a risky late Friday discharge.
Edna Bulmer
Historic (No Identified Response)
2014-0346
25 Jul 2014
Dovecote Lodge
Care Home Health related deaths
Concerns summary
The care home had inconsistent fall risk assessments for Mrs. Bulmer, failed to promptly implement identified risk-minimising measures, and did not review the assessment after multiple falls, indicating systemic failures in falls prevention.
Jane Dyson Gabbitas
Historic (No Identified Response)
2013-0326
12 Dec 2013
South West Yorkshire Partnership NHS Fo…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being unaware of a resident's prolonged disappearance until her body was discovered.
Peter Patrick Adrian Barnes
Historic (No Identified Response)
2013-0291
8 Nov 2013
[REDACTED]
Mental Health related deaths
Concerns summary
Hospital systems were inadequate for communicating observed patient information and serious incidents from nursing staff to the Responsible Clinician, leading to incomplete or outdated data for care decisions.