“(brief summary of matters of concern) i) The absence of training for staff on the ward in…”

The coroner’s concerns

(brief summary of matters of concern) i)    The absence of training for staff on the ward in respect of the correct fitting of a hard collar; ii)   The absence of communication by the treating clinicians with the neurosurgical team at Leeds in respect of treatment options for Kore given the significant impact that the wearing of the collar was having on Kore with the development of pressure sores, difficulties with her swallow and increasing risks of aspiration. iii)   The absence of any consideration of the risks versus benefits of wearing the collar and consequently the lack of opportunity for Kore to consider the risk versus benefits and make an informed decision as to how she wanted to proceed. iv)   The lack of communication between professionals providing care on the ward and the concerns they were raising as to the impact of the collar upon Kore’s health and the absence of any consideration of those concerns by those in charge of Kore’s care with no multi-disciplinary approach as to the available treatment options or further assessments which could have been undertaken.

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, 2025-0441

Added to Minute Book

8 Oct 2026

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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