Alan Horrocks
28 Oct 2025 · Coroner Peter Merchant · West Yorkshire Western
The coroner's concerns
1. lack of overnight observations on ward
“observations were not completed on the ward overnight on 14 March 2025 in accordance with escalation guidance with no documented reason”
2. inadequate response to rising NEWS score
“NEWS score of 5 required further observations and possible escalation”
3. increased patient load without additional staffing
“ward bed capacity had been increased from 27 to 33 beds owing to winter pressures with no corresponding change to the nursing establishment on the ward”
4. insufficient nursing staff on ward
“gaps in the existing nursing establishment on the ward”