Kore Padgett
28 Aug 2025 · Coroner Charlotte Keighley · West Yorkshire West
The coroner's concerns
1. inadequate staff training on hard collar fitting
“The absence of training for staff on the ward in respect of the correct fitting of a hard collar”
2. lack of communication with neurosurgical team
“The absence of communication by the treating clinicians with the neurosurgical team at Leeds in respect of treatment options for [the deceased] given the significant impact that the wearing of the collar was having on [the deceased] with the development of pressure sores, difficulties with her swallow and increasing risks of aspiration”
3. lack of informed consent process
“The absence of any consideration of the risks versus benefits of wearing the collar and consequently the lack of opportunity for [the deceased] to consider the risk versus benefits and make an informed decision as to how she wanted to proceed”
4. absence of multidisciplinary response
“The lack of communication between professionals providing care on the ward and the concerns they were raising as to the impact of the collar upon [the deceased]'s health and the absence of any consideration of those concerns by those in charge of [the deceased]'s care with no multi-disciplinary approach as to the available treatment options or further assessments which could have been undertaken”