“During the course of the evidence it became clear that when Pinderfields Hospital (the…”
Dated 21 Oct 2015, from the coroner for South Yorkshire East. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 16 Dec 2015. A reply may have been sent and not yet published.
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.
- Report dated21 Oct 2015
- Deadline16 Dec 2015
- Published on judiciary.uk21 Oct 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Mid Yorkshire Teaching NHS TrustNamed in the report as “Mid Yorkshire NHS Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Leeds Teaching Hospitals NHS Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospital Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper's recent medical history. It was clear that had that information been provided, the Clinical picture would have pointed more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this. My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture. Matters of concern in summary are : 1. The absence of clear procedures for those in MDT meetings to proactively follow up inadequately completed referral forms. 2 Lack of procedures to proactively obtain information to complete gaps in clinical history
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, 2015-0412
- 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
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