West Yorkshire (Western)
Coroner Area
Reports: 98
Earliest: Nov 2013
Latest: 28 Oct 2025
64% response rate (above 62% average).
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
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.
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
The coroner highlighted a general concern about the appropriateness of reviewing an unspecified practice, suggesting a need for internal re-evaluation.
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
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.
Dilys Etchells
All Responded
2021-0428
23 Dec 2021
Aden Nursing Home
Care Home Health related deaths
Concerns 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.
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
There is a concern that patient sensitivities to antibiotics are ignored, leading to medication being administered despite potential risks.
Mohammad Farhan
All Responded
2021-0323
29 Sep 2021
Harden & Bingley Park Ltd
Child Death (from 2015)
Other related deaths
Concerns summary
Safety signs prohibiting swimming were obscured by vegetation and were old, making them less noticeable and explicit about the dangers of the water.
Maya Zab
All Responded
2021-0316
16 Sep 2021
NHS England
Department of Health and Social Care
Child Death (from 2015)
Concerns summary
There's been an concerning increase in severe nutritional anaemia and related deaths in children, potentially due to reduced health consultations, limited social contact, and widening socio-economic inequalities exacerbated by the pandemic.
Chloe English
All Responded
2021-0317
15 Sep 2021
Calderdale Council
Suicide (from 2015)
Concerns 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.
Judith Varley
All Responded
2021-0210
21 Jun 2021
Wilsden Medical Practice
Community health care and emergency services related deaths
Concerns 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.
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
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.
Susan Roberts
All Responded
2021-0195
7 Jun 2021
Bradford Royal Infirmary
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Danielle Broadhead
All Responded
2021-0104
15 Apr 2021
Roads and Highways – Kirklees Council
Road (Highways Safety) related deaths
Concerns 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.
Emma Dorman
All Responded
2021-0071
11 Mar 2021
South West Yorkshire Partnership
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
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
Inadequate record-keeping of care provided and medication dosage made it impossible to corroborate staff actions and risked erroneous or duplicated patient care.
Miles Naylor
All Responded
2020-0005
10 Jan 2020
Bradford District Care NHS Trust
Mental Health related deaths
Suicide (from 2015)
Concerns 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.
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
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.
Antony Rogivska
All Responded
2019-0251
26 Jul 2019
Calderdale Council Highways Department
Road (Highways Safety) related deaths
Concerns summary
Dangerous road junctions and mini-roundabouts have a history of serious collisions, with ongoing safety concerns repeatedly raised by local residents and campaigners.
Robert Norton
All Responded
2019-0295
21 Jan 2019
Calderdale Council
Road (Highways Safety) related deaths
Concerns summary
Unclear road markings and a confusing road layout contributed to motorist confusion, posing a risk of future accidents.
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
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.
Jordan Sheils
All Responded
2018-0319
16 Oct 2018
Calderdale Metropolitan Borough Council
Road (Highways Safety) related deaths
Concerns 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.
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
Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent surgery after sustaining trauma.
Peter Gledhill
All Responded
2018-0371
27 Aug 2018
Midgehole Working Mens Club
Other related deaths
Concerns 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.
Kathleen Bamforth
All Responded
2018-0247
20 Jul 2018
Department for Health
Community health care and emergency services related deaths
Concerns summary
Concerns exist regarding current practice guidelines for clomipramine prescription, specifically the merits of routine blood screens for patients on long-term use.
George Dyson
All Responded
2018-0168
29 May 2018
Calderdale Council
Suicide (from 2015)
Concerns summary
The urgent need to review and implement protective safety measures on North Bridge to prevent further fatalities, following previous similar incidents.
Isaac Brocklehurst
All Responded
2016-0486
18 Oct 2016
Incommunities
Other related deaths
Concerns summary
There is a concern about the safety of pedestrian gaps in a low perimeter wall within a communal grassed area, requiring review to protect playing children.