Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0298, written 13 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Jun 2025 |
|---|---|
| Reference | 2025-0298 |
| Deceased | Chloe Ellis |
| Coroner | Oliver Longstaff |
| Coroner area | West Yorkshire (East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Mid Yorkshire Teaching NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
OFFICE OF THE
SENIOR CORONER
for the County of West Yorkshire
(Eastern District)
His Majesty’s Coroner’s Office
The Coroner’s Courts
Burgage Square
Wakefield WF1 2TS
Telephone:
Email:
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
1. West Yorkshire Integrated Care Board (ICB), White Rose House, West Parade, Wakefield
WF1 1LT
CORONER
I am Oliver Robert Longstaff, Area Coroner for the Coroner Area of West Yorkshire (East).
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of The Coroners (Investigations) Regulations 2013.
INVESTIGATION and INQUEST
On 06 September 2024 I commenced an investigation into the death of Chloe Alicia Ellis who
died on 03 September 2024 in Leeds General Infirmary. The investigation concluded at the end
of the Inquest on 09 June 2025. The medical cause of death was 1a) Pulmonary Embolism; 1b)
Endometriosis, Treated with Oral Contraceptive Pill.
In summary, the narrative conclusion to the inquest was that, had a history of her oral
contraceptive use been obtained when Chloe attended a local hospital Emergency Department
on 31 August 2024, she would have been given anticoagulation medication and undergone
tests that would have revealed the pulmonary embolism. She would have received effective
treatment for the pulmonary embolism and, on the balance of probabilities, would not have died
three days later.
2
3
CIRCUMSTANCES OF THE DEATH
4
Chloe Ellis had been taking the Yasmin contraceptive pill to manage her endometriosis since
September 2023.
On 31 August 2024 she undertook an NHS 111 online assessment in which she reported chest
and back pain and breathlessness and gave a history of her oral contraceptive use. The
assessment algorithm advised her to attend a local Emergency Department, having concluded
via the algorithmic process that she had a suspected pulmonary embolism. The assessment
algorithm did not tell Chloe herself that she had a suspected pulmonary embolism.
The outcome of the NHS online assessment was not available to clinical staff at the Emergency
Department at Dewsbury District Hospital where Chloe attended. There, an inadequate history
was obtained from her, in that she was not asked about her medication history and specifically
about her use of oral contraception. The inquest was informed of measures taken by the Mid
Yorkshire Teaching NHS Trust in relation to that inadequate history taking, and no Reg 28
report is being made in respect of it.
Chloe was diagnosed with a viral illness and discharged. She collapsed at home on 03
September 2024 and, despite the best efforts of attending paramedics and clinicians at Leeds
General Infirmary, she died later that day.
CORONER’S CONCERNS
During the course of the Inquest the evidence revealed matters giving rise to concern. In my
opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it
is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
(1) The inquest was told that it is possible for the outcomes of NHS 111 online assessments to
be made accessible to Emergency Department clinicians, and that the decision whether or not
to commission that accessibility in a particular hospital rests with the relevant Integrated Care
Board.
5
(2) The inquest was told that the West Yorkshire Integrated Care Board has not commissioned
accessibility to NHS 111 online assessments for the Mid Yorkshire Teaching NHS Trust.
(3) If the NHS online assessment completed by Chloe had been available to the relevant
clinicians at Dewsbury District Hospital, her history of oral contraceptive use and the suspicion
of a pulmonary embolism would have been visible to them.
(4) The availability of NHS 111 online assessments to clinicians in Emergency Departments
may assist in the obtaining of a full history and may act as a failsafe against inadequate history
taking in Emergency Departments.
ACTION SHOULD BE TAKEN
6
In my opinion action should be taken to prevent future deaths and I believe you or your
organisation have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely
by 08 August 2025. I, the Coroner, may extend the period.
7
Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
Chloe’s family;
Mid Yorkshire Teaching NHS Trust.
I am also under a duty to send the Chief Coroner a copy of your response.
8
The Chief Coroner may publish either or both in a complete or redacted or summary form. He
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the Coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.
Signed:
9
OLIVER LONGSTAFF
Area Coroner
West Yorkshire (East)
Date: 13 June 2025
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
White Rose House
West Parade
Wakefield
WF1 1LT
Visit: www.wypartnership.co.uk
Twitter: @WYpartnership
Friday 8th August 2025
Oliver Longstaff
Area Coroner
West Yorkshire (East)
Via email:
Dear Mr Longstaff,
Thank you for your letter of 13th June 2025 in relation to the Regulation 28 report to
prevent future deaths following the inquest into the death of Chloe Ellis. This was
issued to the West Yorkshire Integrated Care Board (WYICB), White Rose House,
West Parade, Wakefield, WF1 1LT.
I would like to offer my sincere condolences to Chloe’s family on behalf of the NHS
West Yorkshire Integrated Care Board. I am sorry for their loss and for the
circumstances surrounding Chloe’s death.
You raised the following Matters of Concern:
• The inquest was told that it is possible for the outcomes of NHS 111 online
assessments to be made accessible to Emergency Department (ED)
clinicians, and that the decision whether or not to commission that
accessibility in a particular hospital rests with the relevant Integrated Care
Board.
• The inquest was told that the WYICB has not commissioned accessibility to
NHS 111 online assessments for the Mid Yorkshire Teaching NHS Trust
(MYTT).
If the NHS online assessment completed by Ms Ellis had been available to the
relevant clinicians at Dewsbury District Hospital, her history of oral
contraceptive use and the suspicion of a pulmonary embolism would have
been visible to them.
•
• The availability of NHS 111 online assessments to clinicians in EDs may
assist in the obtaining of a full history and may act as a failsafe against
inadequate history taking in EDs.
I will respond to these points and hope to provide assurance around actions that
WYICB is taking as a result.
111 Online Assessments and Data Sharing
Timely access to comprehensive medical records — including NHS 111 online
assessments — is an important contributor to supporting effective and safe clinical
assessments within Emergency Departments (EDs). At the time of the case involving
Chloe, no Emergency Departments across West Yorkshire had access to NHS 111
Online assessment data. This meant that the assessment information could not be
shared with Emergency Department clinicians.
At present, NHS 111 Online is commissioned nationally by NHS England (NHSE)
and not directly by the West Yorkshire Integrated Care Board (WYICB). When a
patient completes an NHS 111 Online assessment, the system advises them on the
most appropriate local service to attend. We have been considering options for the
development of “interoperable” systems locally that can routinely share data,
including these assessments, between NHS111 and EDs.
However, there is now a national solution in development which is designed to
enable the safe, structured transfer of such information across systems. This is
called the Booking and Referral Standard (BaRS). Our approach will be to use the
BaRS in West Yorkshire.
Implementation of the Booking and Referral Standard (BaRS)
BaRS is a national interoperability standard that enables the secure sharing of
patient information, supporting both clinical care and operational processes. It is
expected to enhance patient safety, especially within urgent and emergency care, by
ensuring essential clinical information is available to clinicians in real-time.
The national development and implementation of BaRS was first signalled in the
2022 Plan for Digital Health and Social Care. NHS England has recently confirmed
that BaRS is now being rolled out to support urgent and emergency care pathways.
Adoption of BaRS is the responsibility of individual NHS trusts and their suppliers.
However, compatibility with many existing NHS IT systems — such as Symphony,
currently used within Mid Yorkshire Teaching Trust (MYTT) — is not yet in place and
still under development. WYICB is working actively with national and local partners
to facilitate this integration. It is anticipated that NHS 111 Online assessment data
could be available to EDs in West Yorkshire by March 2026.
Broader Efforts to Improve Access to Clinical Information
In addition to supporting BaRS implementation, WYICB is also promoting access to
medical histories through the Yorkshire and Humber Care Record, which offers
clinicians improved visibility of a patient’s broader health information. This is another
important step towards more joined-up and informed care. Medical history
information is shared via the Yorkshire and Humber Care Record, providing
clinicians with a holistic view of a patient’s health. This comprehensive information
enables clinicians to make a more informed assessment.
We are aware that the inquest into the death of Chloe was informed of actions being
taken by Mid Yorkshire Teaching Trust to improve the assessment of patients
presenting at the Emergency Department. WYICB is committed to working in close
partnership with MYTT to further support these improvements.
I hope this letter provides reassurance of our commitment to improving both patient
safety and interoperability between services. We will continue to engage with
colleagues from both MYTT and NHSE to support continued improved
interoperability and transfer a critical patient information.
Should you have any further questions, or need for clarification please do not
hesitate to contact me again.
Yours sincerely,
Chief Executive NHS West Yorkshire Integrated Care Board
West Yorkshire Health and Care Partnership
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