West Yorkshire (Western)
Coroner Area
Reports: 98
Earliest: Nov 2013
Latest: 28 Oct 2025
64% response rate (above 62% average).
Ricky Barcock
Partially Responded
2019-0462
21 Sep 2019
Oasis Recovery Communites
Treatment Direct Limited
Alcohol, drug and medication related deaths
Concerns summary
The client wellbeing check protocol during sleep needs review to ensure effective physical checks and rousing clients, especially drug users, to properly monitor their wellbeing.
Taejelle Francois
Historic (No Identified Response)
2019-0297
16 Sep 2019
Calderdale and Huddersfield NHS Trust
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A critically ill patient was taken to the A&E waiting area without visual assessment by reception or triage, missing crucial opportunities for early intervention and escalation of care.
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.
Owen Williams
Partially Responded
2019-0250
25 Jul 2019
Sixth Form Colleges Association
Universities and Colleges Admissions Se…
Department for Education
Other related deaths
Concerns summary
The electronic release of A-level results at 6:00 am, hours before student support was available, left vulnerable students without immediate guidance, contributing to a tragic outcome after disappointing grades.
Bram Radcliffe
Historic (No Identified Response)
2019-0110
22 Mar 2019
Communities and Local Government
Ministry of Housing
Stone Federation of GB
Product related deaths
Concerns summary
Dangerous, substandard fireplace surround installations are unregulated as they are not deemed "building work." There is no British Standard for fixing these components, only for their manufacture, creating a safety gap.
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.
Barnaby Aylward
Partially Responded
2018-0387
14 Dec 2018
SW Yorks NHS Trust
Together Housing
West Yorkshire Fire and Rescue Service
Community health care and emergency services related deaths
Concerns summary
Systemic failure in multi-agency review and responsibility for known home safety risks linked to mental illness was compounded by poor communication and inadequate mental health documentation. Family support was also insufficient.
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.
Stanford Bell
Unknown
30 Jul 2018
Care Home Health related deaths
Concerns 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.
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.
Brian Bicat
Partially Responded
2018-0277
29 May 2018
Alliance Pharmaceutical
Diprobase Bayer Public Limited
NHS England
+4 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Inadequate fire hazard warnings on paraffin-based emollient packaging, insufficient awareness among healthcare professionals and the public, and inconsistent prescribing system alerts pose significant fire risks.
Grahame Searby
Historic (No Identified Response)
2018-0162
23 May 2018
South West Yorkshire NHS Trust
Community health care and emergency services related deaths
Suicide (from 2015)
Concerns summary
The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review of operational systems to improve data access.
Mwitumwa Ngenda
Historic (No Identified Response)
2018-0167
20 May 2018
Calderdale Council
Suicide (from 2015)
Concerns summary
Concerns focus on the urgent need for preventative measures and design changes on Scammonden Bridge to prevent future suicide attempts.
Marko Petrovic
Historic (No Identified Response)
2017-0354
15 Sep 2017
Health and Safety Executive
Accident at Work and Health and Safety related deaths
Concerns summary
There are no written guidelines for dismantling cantilevered scaffolds, nor are specific Risk Assessment Method Statements (RAMS) required for this process, risking worker safety.
Pauline Taylor
Partially Responded
2017-0330
21 Jul 2017
Arjo Huntliegh
Thornton and Ross Ltd
Proprietary Association
+6 more
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside insufficient patient risk assessments.
Rebecca Shaw
Historic (No Identified Response)
2017-0067
8 Feb 2017
Phuket Highway District
Road (Highways Safety) related deaths
Concerns summary
The road layout at the junction was unsafe, with obstructed views of oncoming traffic and an inadequate central reservation, increasing the risk of collisions.
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.
Keith Ruston
Historic (No Identified Response)
2016-0483
13 Sep 2016
Department of Health and Social Care
Community health care and emergency services related deaths
Concerns
On the 22/12/2016 opened an inquest into the death of Keith William Rushton who, at the date of his death was 78 years old. The inquest was resumed and concluded on 31/8/2016. Ifound that the cause...
Christine Dryden
Historic (No Identified Response)
2016-0490
17 Aug 2016
Incommunities
Other related deaths
Concerns summary
The absence of regular checks on installed smoke and heat detectors in properties presents a safety risk, necessitating a review of maintenance arrangements.
Khazna Khalaf
Historic (No Identified Response)
2016-0489
18 Jul 2016
St Marien Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Local protocols and hospital guidelines were ineffective in alerting clinicians to ecstasy toxicity risks and symptoms, lacking a clear clinical protocol for initial intervention decisions and monitoring.