“Evidence at the inquest indicated that any referral to SPA classed as non-urgent may take…”
Dated 9 Apr 2026, from the coroner for West Yorkshire (Western). 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 4 Jun 2026.
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 dated9 Apr 2026
- Deadline4 Jun 2026
- Published on judiciary.uk10 Apr 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South West Yorkshire Partnership Teaching NHS Foundation TrustNamed in the report as “South West Yorkshire Partnership NHS Foundation Trust” | Response publishedPublished on judiciary.uk in April 2026. |
The coroner’s concerns
Evidence at the inquest indicated that any referral to SPA classed as non-urgent may take up to 14 days to triage relecting the SPA Standard Operating Procedure. The referrals to SPA could come from anyone, not necessarily someone with experience of mental health conditions. It was only following a triage of a referral and the outcome of the triage would a plan be devised to take forward a referral.
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, 2026-0208
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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