West Yorkshire Western

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

64% response rate (above 63% average).

Clear 52 results
Alan Horrocks
All Responded
2025-0545 28 Oct 2025
Bradford Teaching Hospitals NHS Foundat…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Patient observations were not completed per escalation guidance, delaying deterioration recognition. Increased ward capacity without corresponding nursing staff and existing staffing gaps compromised patient care.
Action Planned (AI summary) The Trust will roll out refresher training for quality governance, patient safety, learning from deaths, and legal staff regarding PSIRF and national guidance on learning from deaths in early 2026. The Trust will also implement a comprehensive Investigation Masterclass Programme.
Ann Laskowsky
All Responded
2025-0502 7 Oct 2025
National College of Policing National Police Chiefs Council
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Inadequate first aid training for police officers in assessing patient conditions and poor awareness of a dedicated medical advice line led to a failure to recognise severe medical needs.
Action Planned (AI summary) The College of Policing will formally raise the case of Ms. Laskowsky at the next meeting of the NPCC First Aid Forum on 4 December 2025, to ensure that national learning is disseminated and embedded. They will produce national learning summaries and practice notes, update Authorised Professional Practice (APP) and training materials, and engage with force training leads and clinical governance advisors. West Yorkshire Police has posted an intranet briefing reminding staff about the YAS Partner Triage Line, included details in operational briefings, updated training and guidance material, and tasked the Right Care Right Person team with monitoring its usage. First Aid trainers will also remind officers of the YAS Partner Triage Line during annual training. The NPCC has recommended that West Yorkshire Police implement clinical governance arrangements consistent with NPCC guidance and has offered support in implementing this. They confirm that assessment of breathing and responsiveness levels are mandated in Learning Outcome 1.3. of Police First Aid Learning Programme.
Kore Padgett
All Responded
2025-0441 28 Aug 2025
Calderdale and Huddersfield NHS Foundat…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to insufficient consideration of treatment options and risks, preventing informed patient decisions.
Action Planned (AI summary) Calderdale and Huddersfield NHS Foundation Trust will implement a Trust-wide training program for applying and managing hard collars, led by senior clinicians, with sessions scheduled for December 2025 and January 2026. They are also developing a Standard Operating Procedure (SOP) for collar initiation and management to be implemented by the end of January 2026, and care plans are being revised to ensure that discussions around risk and benefit are documented clearly within the Electronic Patient Record (EPR).
Mohsin Janjua
All Responded
2025-0407 5 Aug 2025
Office for Product Safety and Standards
Product related deaths
Concerns summary (AI summary) The unregulated online sale of substandard lithium-ion batteries for e-bikes poses a significant fire risk, with online marketplaces currently disclaiming safety responsibility. This highlights the need for stronger regulations and public awareness.
Action Taken (AI summary) OPSS has taken enforcement action against unsafe e-bike batteries, working with online marketplaces to remove dangerous products. They also launched a 'Buy Safe, Be Safe' campaign to raise public awareness of e-bike safety, producing videos in multiple languages and sharing them with gig economy companies.
Myles Scriven
All Responded
2025-0356 11 Jul 2025
CQC North Dalton Surgery NHS England
Community health care and emergency services related deaths
Concerns summary (AI summary) GPs demonstrated insufficient understanding of Learning Disability and Autism needs, resulting in inadequate adjustments and ineffective use of the Learning Disabilities Register, contributing to a lack of appropriate secondary care referral.
Action Planned (AI summary) NHS England is advised that the involved GP surgery has taken learnings from Myles’ death, including improved processes for managing patients with learning disabilities and autism and reminding staff of the importance of accurate documentation. NHS England has also been engaging with NHS West Yorkshire Integrated Care Board on the concerns raised. Dalton Surgery has implemented a range of actions including Oliver McGowan mandatory training, Practice Protected Time meetings, and enhanced communication. The practice has developed a detailed action plan with auditable evidence and clear timescales, working with ICB colleagues. CQC has been in contact with Dalton Surgery to establish the full circumstances and request information about their planned actions; they have received an action plan. CQC will use the Oliver McGowan Code of Practice when considering whether providers are meeting regulatory requirements; bespoke upskilling sessions will be run for inspection teams. The CQC has contacted Calderdale and Huddersfield NHS Foundation Trust and will receive information about actions taken to prevent a reoccurrence. The CQC will also use the Oliver McGowan Code of Practice when considering whether providers are meeting training requirements and upskill inspection teams on the mandatory training.
Paul Alexander
All Responded
2025-0244 27 May 2025
West Yorkshire Police
Emergency services related deaths (2019 onwards) Mental Health related deaths Police related deaths
Concerns summary (AI summary) Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency services to respond to mental health welfare concerns, a known recurring issue.
Action Taken (AI summary) West Yorkshire Police has worked with partners to develop an escalation process for RCRP, including briefings, training, and revised policies to improve identification and mitigation of risks related to mental health. The force continues to work with partners to share learning, address gaps, and improve service delivery.
Andrea Mann
All Responded
2025-0130 6 Mar 2025
Bradford District Care NHS Trust
Mental Health related deaths Suicide (from 2015)
Action Taken (AI summary) The Trust has implemented a routine re-referral process with management oversight for service users re-referred to Community Mental Health Services within 6 months, improved assessment processes, and streamlined referral pathways. They have also committed to improving the timeliness of support available within four weeks of referral.
Arsalan Baig
All Responded
2025-0129 6 Mar 2025
Bradford Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) Inadequate street lighting and missing traffic warning signs at a sharp turn towards a wall significantly contributed to a fatal road accident.
Action Taken (AI summary) Bradford Council installed a new street lighting column, a chevron sign, and a "Left Bend Ahead" warning sign at the corner of Dryden Street and Buck Street.
Mohammed Khan
All Responded
2025-0128 6 Mar 2025
Bradford Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) Insufficient street lighting and a lack of warning signs at a poorly marked 90-degree turn and dead-end contributed to a fatal road traffic accident.
Action Taken (AI summary) Following a fatal collision, Bradford Council installed a new street lighting column, a chevron sign, and a "Left Bend Ahead" warning sign at the accident location.
Raymond Jennings
All Responded
2025-0125 6 Mar 2025
Abbey Place Nursing Home
Care Home Health related deaths
Concerns summary (AI summary) The care home failed to promptly obtain prescribed antibiotics or seek medical care for a deteriorating resident, and could not demonstrate improved systems to prevent reoccurrence of this significant failing.
Action Taken (AI summary) The nursing home has updated its medication policy, implemented an electronic medication system and digital care planning system, changed GP and pharmacy providers, and completed documentation training with all staff.
Joseph Walsh
All Responded
2025-0023 13 Jan 2025
Department for Transport
Road (Highways Safety) related deaths
Concerns summary (AI summary) There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and warrants a review of current provisions.
Action Planned (AI summary) The Department for Transport is developing a road safety strategy and exploring options to tackle the root causes of incidents involving young drivers and is also considering further policy options regarding motoring offences.
Tobias Barraclough
All Responded
2025-0022 13 Jan 2025
Department for Transport
Road (Highways Safety) related deaths
Concerns summary (AI summary) There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and warrants a review of current provisions.
Action Planned (AI summary) The Department for Transport is developing a road safety strategy and exploring options to tackle the root causes of incidents involving young drivers and is also considering further policy options regarding motoring offences.
Angela Carney
All Responded
2025-0021 13 Jan 2025
Department for Transport Medicines & Healthcare products Regulat…
Product related deaths Road (Highways Safety) related deaths
Concerns summary (AI summary) Many mobility scooters, especially older models, lack a crucial secondary hand brake system, creating significant safety risks for riders and the public. Guidelines need reviewing.
Action Planned (AI summary) The MHRA is working on updating its "Medical devices: information for users and patients" guidance to raise awareness on important considerations prior to purchasing a mobility scooter, with publication expected by June 2025, and will collaborate with relevant stakeholders to disseminate this information. The Department for Transport will liaise with the MHRA to establish whether anything further can be done to prevent such deaths, such as providing information to mobility scooter users about the risks of operating in freewheel mode and warning about the absence of a secondary brake on older models.
Gemma Marshall
All Responded
2025-0001 2 Jan 2025
NHS England Royal College of Radiologists
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) An outsourced radiologist with insufficient expertise misreported a CT scan, failing to identify a slipped gastric band due to a lack of specialist knowledge, compounded by staff shortages.
Action Planned (AI summary) NHS England shared national guidance on teleradiology, regional colleagues engaged with West Yorkshire ICB, Calderdale and Huddersfield NHS Foundation Trust conducted an After Action Review and REALM teaching session, and discrepancies in reporting were shared with the external provider who will investigate. All reports received are discussed by the Regulation 28 Working Group. The Royal College of Radiologists acknowledged the importance of interpreting radiology in clinical context, emphasized learning from events, and will consider the case theme and signpost a suitable anonymized CT from a different patient in educational material.
Alfie Hinton
All Responded
2024-0658 2 Dec 2024
Airedale NHS Foundation Trust
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and absence of policy between consultants during a time-critical spinal anaesthetic procedure also caused significant delays.
Action Taken (AI summary) Airedale NHS Foundation Trust reported the case to the Healthcare Safety Investigation Branch (HSIB), undertook an internal investigation, accepted HSIB recommendations, and accepted the independent expert report. They detailed actions including updated policies, training, and revised observation procedures.
Geoffrey Cheney
All Responded
2024-0561 18 Oct 2024
Radis Community Care
Community health care and emergency services related deaths Suicide (from 2015)
Concerns summary (AI summary) An unsubstantiated assumption that something could not be removed led to a failure to even attempt its removal, which could have been crucial.
Noted (AI summary) Radis Community Care states that they generally do not remove minor aids and adaptations once fitted, as it is the responsibility of the homeowner, landlord or tenant to remove them. Exceptions are made for re-usable items or safeguarding concerns. Kirklees Council amended its Housing Assistance Policy to reflect that they may remove adaptations should they pose any risk to any persons in the household. The council will raise a Safeguarding Adults Review (SAR) referral to help identify any learning for future purposes.
Mason Portman
All Responded
2024-0477 27 Aug 2024
National Highways
Road (Highways Safety) related deaths
Concerns summary (AI summary) The absence of appropriate road markings and signage on a slip road regarding speed or curvature ahead created dangerous driving conditions.
Disputed (AI summary) National Highways investigated the incident and states that the current layout and signing strategy comply with best practice guidance and legislative requirements and therefore they do not propose any alterations to the current junction layout or speed limit along the slip road, except for replacing a damaged sign.
Archie Bruce
All Responded
2024-0205 18 Apr 2024
Rugby Football League
Alcohol, drug and medication related deaths
Concerns summary (AI summary) The Rugby Football League's Welfare Policy allows clubs outside the Super League to relax illicit drug education and conduct rules, risking young players who need consistent guidance due to their immaturity.
Action Planned (AI summary) The RFL will review its Overseas Code of Conduct, with specific reference to player behaviour, this year. Ongoing training will reflect any changes made.
Kyle Goater
All Responded
2024-0057 5 Feb 2024
Ilkley Town Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) The absence of advance warning signs for a layby situated at the bottom of a dip on a 50mph road created an unforeseen hazard, contributing to a fatal collision.
Action Taken (AI summary) The council has installed bollards to prevent access to the informal layby, removed the intermittent white line, and ordered a Hidden Dip warning sign. Consultation on a proposed speed limit is to commence this month (October 2024) with formal advertising in November followed by the sealing of the order in December, subject to no objections.
Shaun Crossfield
All Responded
2024-0054 2 Feb 2024
RPAS
Other related deaths
Concerns summary (AI summary) The absence of a regulatory authority and mandatory inspections for "class BGD Luna 2 Paraglider" aircraft allowed unchecked self-repairs, leading to a fatal accident due to a propeller defect.
Noted (AI summary) The BHPA states it is not a regulatory authority and has no powers of compulsion. They will continue to encourage people who wish to fly aircraft to join the Association and to undertake and complete their training programmes. The CAA will publish new safety guidance on maintaining the airworthiness of SPHG aircraft, incorporated into the Paramotor Code by September 2024. They will also begin a project by November 2024 to explore ways to improve pilot performance and knowledge, including assessing the need for additional training regulation.
Peter Stajic
All Responded
2024-0053 1 Feb 2024
Yorkshire Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) Paramedics lacked training in identifying a herald bleed and had no specific protocol to follow, despite its critical nature in specialist vascular knowledge.
Action Planned (AI summary) The Association of Ambulance Chief Executives will develop new guidance for paramedics on recognising infected surgical wounds at risk of catastrophic bleeding, to be included in existing vascular emergencies guidance. This will be pushed out as a clinical update onto the App following approvals from JRCALC and NASMeD within approximately three months.
Maxwell Frame
All Responded
2023-0449 14 Nov 2023
Association of Anaesthetists Department of Health and Social Care National Infusion and Vascular Access S… +2 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The absence of a national policy for Central Venous Catheter (CVC) placement leads to inconsistent and potentially unsafe practices across hospitals. A standardised national policy is needed to ensure patient safety.
Noted (AI summary) NIVAS plans to publish guidelines in 2024 concerning the use of real time ultrasound guidance for central venous catheter insertion and the identification and management of inadvertent arterial puncture. They will also give the subject prominence at their annual conference in June 2024. The Association of Anaesthetists, Royal College of Anaesthetists, Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS) will ensure that updated "Safe Vascular Access" guidance has more explicit recommendations for checking CVC placement. The ICS is also developing a guideline for managing inadvertent arterial puncture during CVC insertion. NICE acknowledges the concerns but states that existing National safety standards for invasive procedures (NatSSIPs), ICS CVC Insertion Safety Checklist 2023, and AAGBI guidance already provide recommendations, and they do not consider that further NICE guidance would add to existing national recommendations. The Department of Health and Social Care acknowledges concerns about the absence of a national policy on CVC placement, but states that existing NICE guidance and national safety standards should inform local standards. They do not consider further action is needed at this time as the clinician departed from existing national recommendations, NICE guidelines and Trust policy.
John Hoare
All Responded
2023-0384 12 Oct 2023
Low Moor Medical Practice
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The report identifies a gross failure to provide basic medical attention in relation to lithium prescribing and dispensing that resulted in the deceased being sectioned.
Action Planned (AI summary) The practice is in discussions with the local pathology lab to ensure Lithium results are sent as individual results to avoid them being overlooked, and with the Medical Director of Bradford District Care Trust regarding the discharge of patients on shared care medication from the mental health team into primary care. Findings will be discussed at a practice meeting and changes will be audited annually, and learning points shared within the Bradford District.
Leah Barber
All Responded
2023-0283 3 Aug 2023
City of Bradford Metropolitan District …
Child Death (from 2015) Suicide (from 2015)
Concerns summary (AI summary) Bradford Council lacked a unified system for overseeing its involvement with vulnerable children, preventing learning from deaths and maintaining departmental disconnect, which risks future fatalities.
Action Taken (AI summary) Following the death, the Council has strengthened processes to ensure organizational oversight where multiple teams are involved and a child dies, with the Director of Children’s Services as the single point of oversight.
Kate Hyatt
All Responded
2022-0192
Hands of Light Academy
Suicide (from 2015)
Concerns summary (AI summary) A 'Hands of Light Academy' allegedly dispenses hallucinogenic substances to attendees, including potentially mentally unwell individuals, without proper consideration for their impact, especially on psychosis sufferers.
Action Planned (AI summary) Hands of Light Academy states they have no record of the deceased as a student but will implement several actions. These include continuing thorough screening of prospective students, educating staff on hallucinogens, maintaining vigilance over student behaviour, and informing authorities if a student or staff member poses a danger.