“S are as follows: 1”
Dated 9 Jun 2021, from the coroner for West Yorkshire (Western). 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 4 Aug 2021. 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 dated9 Jun 2021
- Deadline4 Aug 2021
- Published on judiciary.uk14 Jun 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Mid Yorkshire 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. |
| South West Yorkshire Partnership Teaching NHS Foundation TrustNamed in the report as “South West Yorkshire Partnership 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. |
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.
S are as follows: 1. Mr Duhaney was a patient at Pinderfield’s Hospital between 23% and 25" June but at no time was he assessed or receive treatment by the in house psychiatric team despite the fact that he had an underlying psychiatric presentation. 2. Pinderfields hospitals discharge protocol does not appear to have been adhered to when Mr Duhaney expressed a wish to self-discharge. 3. No one from Pinderfield’s Hospital contacted Kirklees Intensive Home Based Treatment Team to notify them of Mr Duhaney’s self discharge. 4. Kirklees Home Based Treatment Team last had contact with Pinderfield’s Hospital on 24 June 2019. It was 6 days later that they made a further call to the hospital seeking an update upon Mr Duhaney. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 3 August 2021. |, the coroner, may extend the period.
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, 2021-0200
- 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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