“(brief summary of matters of concern) (1) The ambulance service pre-alerted the hospital…”
Dated 30 Jul 2025, from the coroner for North Yorkshire and York. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 24 Sep 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated30 Jul 2025
- Deadline24 Sep 2025
- Published on judiciary.uk31 Jul 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| York and Scarborough Teaching Hospitals NHS Foundation TrustNamed in the report as “York & Scarborough NHS Trust” | Response publishedPublished on judiciary.uk in July 2025. |
The coroner’s concerns
(brief summary of matters of concern) (1) The ambulance service pre-alerted the hospital regarding Joanne’s serious condition but this did not result in her being prioritised and placed in Resus on arrival. Joanne was wearing two medic alert bracelets to draw attention to her diagnoses of APS and AD but these were not observed by the treating team. There were no visible ’red flags’ on Joanne’s medical records, highlighting her APS and AD diagnoses to the treating team. The treating doctor relied on a very sick patient to confirm any underlying medical conditions. There was no liaison with Rheumatology, who had extensive knowledge and experience of Joanne and how to treat her conditions. (2) There was delay in Joanne receiving fluids, which led to hypoglycaemia which was then not treated promptly. (3) It was not clear from the medical notes that staff treating Joanne had considered the relevance of her APS and AD in her treatment plan.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0393
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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