“(brief summary of matters of concern) Although detailed expertise concerning a herald…”
Dated 1 Feb 2024, 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
Deadline passedReplies were due by 28 Mar 2024. 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 dated1 Feb 2024
- Deadline28 Mar 2024
- Published on judiciary.uk12 Feb 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Yorkshire Ambulance Service NHS TrustNamed in the report as “Yorkshire Ambulance Service” | 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
(brief summary of matters of concern) Although detailed expertise concerning a herald bleed is specialist vascular knowledge that the paramedics who attended Peter at his home on the morning of 26 February 2022 would not be expected to possess, the evidence to the Inquest was that they would not have had any training in identifying one, nor any protocol for them to follow.
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, 2024-0053
- 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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