West Yorkshire Western

Coroner Area
Reports: 100 Earliest: Nov 2013 Latest: 9 Apr 2026

64% response rate (above 63% average).

Clear 52 results
Rita Britten
All Responded
2022-0162
NHS England Resuscitation Council UK
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Lack of clear national guidelines for effectively managing choking emergencies in overweight/obese individuals, where conventional abdominal thrusts are compromised, creates a significant safety risk.
Noted (AI summary) NHS England notes the Coroner's concerns and is assured by the Resuscitation Council UK's response, stating that the specific circumstances are not within NHS England's direct statutory responsibility. The concerns have been shared with the National Patient Safety Team and discussed by a Regulation 28 Working Group. The Resuscitation Council UK clarifies that its existing basic life support guidelines cover foreign body airway obstruction for all individuals and includes e-learning modules. They have assessed suction-based devices but found insufficient evidence to advocate for their routine use.
Daniel Clements
All Responded
2022-0209 13 Jul 2022
Department of Health and Social Care South West Yorkshire Partnership NHS Fo…
Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) A systemic void exists for vulnerable individuals with suicidal ideation but no overt psychiatric illness, leading to them being passed between agencies without effective crisis intervention or multidisciplinary planning.
Noted (AI summary) The Trust acknowledges the concerns and describes its general approach to suicide prevention, emphasizing collaboration with partner organizations to address social needs but offers no specific changes. The Department acknowledges the concerns, explains the limits of the Mental Health Act, and references existing NHS England initiatives and investment in community mental health services and integrated care.
Faizan Nazar
All Responded
2022-0101 4 Apr 2022
Spire Harpenden Hospital
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Railway related deaths Suicide (from 2015)
Concerns summary (AI summary) The coroner highlighted a general concern about the appropriateness of reviewing an unspecified practice, suggesting a need for internal re-evaluation.
Noted (AI summary) The consultant psychiatrist will now email his secretary of planned follow-ups for patients and advise her to remind the patient two weeks before the scheduled time to make an appointment. If they do not respond, the GP will be informed that they are no longer attending the clinic. No actions or stance were discernible from the provided text.
Edward Akroyd
All Responded
2022-0069 4 Mar 2022
Calderdale and Huddersfield Foundation …
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) No specific concerns identified within the provided text, which details a critical condition and subsequent death following an expedited delivery due to abnormal CTG tracing.
Noted (AI summary) The Trust outlines actions taken in response to concerns, including updating guidelines for maternal blood pressure checks and CTG interpretation, changing processes for escalating concerns, and ensuring timely review of blood test results. They also describe actions related to training and competence assessment of midwives. The Trust requests redaction of specific concerns and responses from publication, arguing they could identify individual clinical staff and contain personal information.
Dilys Etchells
All Responded
2021-0428 23 Dec 2021
Aden Nursing Home
Care Home Health related deaths
Concerns summary (AI summary) The care home showed inadequate provision and documentation of safety equipment, poor note-taking, insufficient staff training in visual checks and handover, and deficient wound management protocols.
Action Taken (AI summary) Aden Court Care Home implemented several changes, including a new Registered Manager, review of crash and sensor mat provision with improved documentation, and amended admission procedures, with ongoing reviews and hospital staff producing initial care plans for residents returning with casts.
Sharon Robinson
All Responded
2021-0385 16 Nov 2021
Bradford Teaching Hospitals NHS Trust
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is a concern that patient sensitivities to antibiotics are ignored, leading to medication being administered despite potential risks.
Action Planned (AI summary) The Trust is working to align its approach to antimicrobial policy with Bradford Teaching Hospitals, overseen by the Drug and Therapeutics Committee, including a revision of the Antimicrobial Policy. The Trust is also engaging with other healthcare providers to understand how they manage the risk of prescribing medication to patients with documented allergies.
Mohammad Farhan
All Responded
2021-0323 29 Sep 2021
Harden & Bingley Park Ltd
Child Death (from 2015) Other related deaths
Concerns summary (AI summary) Safety signs prohibiting swimming were obscured by vegetation and were old, making them less noticeable and explicit about the dangers of the water.
Action Planned (AI summary) Harden & Bingley Park Ltd will erect more signs around the Goit Stock waterfall area, and has provided photos of the proposed signs.
Maya Zab
All Responded
2021-0316 16 Sep 2021
Department of Health and Social Care NHS England
Child Death (from 2015)
Concerns summary (AI summary) The report notes an increased incidence of severe nutritional anaemia in children in the Yorkshire & Humber region in 2020, potentially linked to factors arising indirectly from the pandemic such as reduced consultations, limited social contact, and widening socio-economic inequalities.
Noted (AI summary) NHS England is integrating care with a focus on addressing inequalities and supporting vulnerable children and families, and will work to raise the profile and uptake of the Healthy Start programme which is in the process of transferring from paper vouchers to digital cards. The Department of Health and Social Care acknowledges the concerns, states that national data does not show a significant increase in diagnoses of iron deficiency anaemia, and outlines existing schemes such as the Healthy Child Programme and Healthy Start scheme aimed at promoting healthy diets. They do not plan to introduce new policies specifically targeting nutritional anaemia.
Chloe English
All Responded
2021-0317 15 Sep 2021
Calderdale Council
Suicide (from 2015)
Concerns summary (AI summary) Existing suicide prevention measures at a known high-risk location proved ineffective, as the deceased was able to jump within minutes of arrival, indicating current safeguards are insufficient.
Action Taken (AI summary) Calderdale Council installed anti-climb mesh, steeple coping, and Samaritan signs on North Bridge in 2019 and improved CCTV coverage. Following a death at the bridge, temporary fencing was installed, a suicide prevention group was convened, and a design for further safety measures costing £1.5M has been agreed with Historic England.
Judith Varley
All Responded
2021-0210 21 Jun 2021
Wilsden Medical Practice
Community health care and emergency services related deaths
Concerns summary (AI summary) Inaccurate computer coding for medical procedures and a lack of auditing or quality control for data input raises concerns about the reliability of patient information.
Action Taken (AI summary) Wilsden Medical Practice updated their coding process, provided staff training, implemented system changes to improve accuracy, and undertook an audit of coding accuracy with plans to repeat it.
Denton Duhaney
All Responded
2021-0200 9 Jun 2021
Mid Yorkshire Hospitals NHS Trust and S…
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) Hospital failed to assess or treat a patient with psychiatric issues, did not follow discharge protocols for self-discharge, and neglected to inform external mental health teams, leading to a dangerous gap in care.
Action Taken (AI summary) Fieldhead Hospital updated their Standard Operational Policy to ensure consistency across Psychiatric Liaison Teams and disseminated guidance to community services for maintaining contact with service users awaiting discharge and the Psychiatric Liaison Team, providing a safety net for transition of care.
Susan Roberts
All Responded
2021-0195 7 Jun 2021
Bradford Royal Infirmary
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was a lack of timely and effective handover between surgical specialties, compounded by an absence of formal protocols and a lack of engagement from plastic surgeons during and after an incident.
Action Taken (AI summary) Bradford Teaching Hospitals issued a protocol for Necrotising Fasciitis cases specifying contact procedures and involved specialties. The Trust also revised its Serious Incident Reporting policy to ensure attendance of all crucial staff at Round Table discussions.
Danielle Broadhead
All Responded
2021-0104 15 Apr 2021
Roads and Highways – Kirklees Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) The existing road layout and measures highlighting the kerb need review to ensure they meet safety regulations, particularly regarding the commencement of the kerb.
Action Planned (AI summary) Kirklees Council will extend the northern footway by 18m to improve pedestrian crossing opportunities on Barnsley Road. These works are part of a footway maintenance scheme started on May 7th 2021.
Emma Dorman
All Responded
2021-0071 11 Mar 2021
South West Yorkshire Partnership
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Non-clinical staff inappropriately influenced patient leave decisions, overriding clinical judgment. Additionally, the ward lacked psychologist input for over three years due to persistent recruitment failures.
Action Planned (AI summary) The Trust is reviewing its Patient Flow Procedure, skill-mix for vacant psychology posts, and will update the Job Description and Person Specification for the vacant part-time Psychologist post in Ward 18, anticipating completion in June 2021 and in the interim a Clinical Psychologist will provide in-reach support.
Leslie Clewarth
All Responded
2020-0229 10 Nov 2020
Mid Yorkshire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate record-keeping of care provided and medication dosage made it impossible to corroborate staff actions and risked erroneous or duplicated patient care.
Action Planned (AI summary) The Trust is revising its Syringe Pump Policy and combined prescription/administration chart to provide clearer guidance on medication recording and syringe changes; further training will be delivered following appropriate governance routes.
Miles Naylor
All Responded
2020-0005 10 Jan 2020
Bradford District Care NHS Trust
Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) Concerns were raised about the management of ligature risks from personal items and the unsafe design of ward doors, specifically regarding access to hinge pins, at a mental health facility.
Action Taken (AI summary) Bradford District Care NHS Foundation Trust has reviewed its policy for Blanket Restrictions and implemented daily safety checks in inpatient areas. Work has begun to install high specification full door alarms on identified bedrooms on 8 high risk wards, due to be completed by April 2020.
Antony Rogivska
All Responded
2019-0251 26 Jul 2019
Calderdale Council Highways Department
Road (Highways Safety) related deaths
Concerns summary (AI summary) Dangerous road junctions and mini-roundabouts have a history of serious collisions, with ongoing safety concerns repeatedly raised by local residents and campaigners.
Action Planned (AI summary) Calderdale Council is undertaking a feasibility study to assess options for improving safety at the Carr House Road/Cooper Lane junction, with a preferred scheme option expected by the end of March 2020 for delivery during the 2020/21 financial year. The study will consider traffic calming, junction improvements, and pedestrian crossing points.
Gladys Sayles
All Responded
2019-0253 26 Jul 2019
Leeds Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Guidelines for Aspen collar use, bespoke training for application, and communication between healthcare providers and suppliers regarding fitting and patient care all require urgent review and improvement.
Noted (AI summary) Leeds Teaching Hospitals NHS Trust reviewed communication between their Neurosurgical Unit and Huddersfield Royal Infirmary and concluded that discussions were timely and advice appropriate. They are satisfied current arrangements are appropriate and responsive. TayCare Medical Ltd provides detailed explanations to patients about assessments and fittings, adds notes to clinical records, and offers open review for assistance with issues. They state they operate safely and are happy to discuss issues further.
Robert Norton
All Responded
2019-0295 21 Jan 2019
Calderdale Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) Unclear road markings and a confusing road layout contributed to motorist confusion, posing a risk of future accidents.
Action Planned (AI summary) Calderdale MBC will continue to inspect the white lining and renew it as required and will commission a study of similar accidents regarding the roundabout layout to determine if any remediation is needed.
Ursula Keogh
All Responded
2018-0370 21 Nov 2018
Calderdale Council Department of Health and Social Care NHS Calderdale Clinical Commissioning G…
Child Death (from 2015)
Concerns summary (AI summary) Inconsistent and contradictory advice from GPs and schools regarding CAMHS referrals, exacerbated by a school lacking the necessary Psychology Team, highlighted poor communication between health and education professionals.
Action Planned (AI summary) The Department of Health and Social Care highlights national initiatives like 'Future in Mind' and the Suicide Prevention Workplan. They also mention plans to set up 24/7 crisis care for children and young people by 2023/24 and efforts with DCMS to address harmful online content. Calderdale CCG and Calderdale Council have reviewed and revised processes and identified new actions related to CAMHS referrals and communication between professionals, overseen by the multi-agency Open Mind Partnership. Calderdale Council is progressing with the installation of anti-climb mesh and CCTV at North Bridge, with completion expected by the end of 2019.
Jordan Sheils
All Responded
2018-0319 16 Oct 2018
Calderdale Metropolitan Borough Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) The council is delaying the implementation of anti-climbing mesh and CCTV cameras on a bridge, despite measures to deter tragedies being under consideration.
Action Planned (AI summary) Calderdale Council submitted planning and listed building consent applications for anti-climb mesh and steeple coping on North Bridge, with works expected to be complete by May 2019. CCTV has been installed. These measures were discussed and agreed with their Public Health colleagues who lead the Suicide Prevention Group.
Michael Hopkins
All Responded
2018-0331 1 Oct 2018
Bradford Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent surgery after sustaining trauma.
Action Planned (AI summary) The Trust has developed a revised patient leaflet regarding blood clot risk assessment, to be introduced on 1st December 2018. The Quality Committee will review the leaflet's use and impact.
Peter Gledhill
All Responded
2018-0371 27 Aug 2018
Midgehole Working Mens Club
Other related deaths
Concerns summary (AI summary) The safety of a pathway running along a steep river embankment requires urgent review, specifically considering the appropriateness of installing fencing to prevent future incidents.
Noted (AI summary) The council states that they do not own the land in question, nor have any legal powers to build a wall or fence. They provide a map indicating ownership of the land adjacent to the pathway.
Stanford Bell
All Responded
30 Jul 2018
Airedale NHS Foundation Trust Riverview Nursing Home
Care Home Health related deaths
Concerns summary (AI summary) Concerns exist over Airedale Hospital's discharge procedures for head injury patients lacking discharge papers and Riverview Care Home's referral procedures for patients experiencing post-trauma seizures.
2 responses from Stanford Bell, Stanford Bell Response2
Kathleen Bamforth
All Responded
2018-0247 20 Jul 2018
Department for Health
Community health care and emergency services related deaths
Concerns summary (AI summary) Concerns exist regarding current practice guidelines for clomipramine prescription, specifically the merits of routine blood screens for patients on long-term use.
Noted (AI summary) The Department of Health acknowledges the concerns and provides information on NICE guidelines and SmPC recommendations for clomipramine and tramadol. The MHRA is seeking advice from experts on routine blood screens during long-term clomipramine use and requests a copy of the coroner's report.