A coroner has warned a York hospital trust there is a "risk of future deaths” if it does not make changes after two individuals died while under its care.

Area coroner Catherine Cundy wrote to the chief executive of the York and Scarborough Teaching Hospitals NHS Foundation Trust following the two unrelated deaths at York Hospital last year.

A trust spokesperson told The Press it takes the coroner’s findings “extremely seriously” and is “committed to act wherever necessary to improve patient safety”.

Ms Cundy prepared the two reports following inquests held into the deaths of Janet Seddon, 79, on February 9, 2023, and Stephen Dulling, 69, on September 4, 2023.

Mrs Seddon died as a consequence of naturally occurring disease contributed to by a delay in correctly identifying her abdominal pathology, an inquest concluded.

Ms Cundy, in her report, said Mrs Seddon underwent a CT scan on January 30, 2023. Eight days later, the images from the scan were re-reviewed and found that her bowel could become obstructed due to her condition.

The same day (February 7, 2023), Mrs Seddon was surgically assessed and consented to an operation to examine her abdominal organs.

She was stable immediately after the operation but her condition “steadily deteriorated with signs of developing sepsis”, the report said.

“Despite intensive care she died at the hospital on February 9, 2023.”

Mr Dulling died from aspiration pneumonia as a consequence of an inappropriate diet as a hospital in-patient at York Hospital, another inquest concluded.

Ms Cundy, in her report following that hearing, said Mr Dulling was admitted to the Acute Medical Unit at York Hospital on August 31, 2023.

He had Parkinson’s Disease, symptoms of dementia and difficulties with swallowing.

On the morning of September 2, 2023, Mr Dulling was “eating toast for breakfast when he started to choke and went into cardiac arrest”, the report said.

“He was subsequently found to have copious amounts of toast in his airway and gastric contents in his lungs leading to aspiration pneumonia.

“Mr Dulling died at the hospital on September 4, 2023.”

Risk of future deaths if changes not made, warns coroner

Following both inquests, the coroner raised concerns about the deaths.

In the case of Mrs Seddon, Ms Cundy, in her report to the chief executive of the York trust, said the “delay in identifying her condition more than minimally contributed to her death”.

The coroner said she was concerned there was risk of future deaths should this happen again.

Writing in her report following the death of Mr Dulling, Ms Cundy outlined concerns to the chief executives of the York trust and the Tees Esk and Wear Valley NHS Foundation Trust (TEWV).

In respect of TEWV, the coroner said Mr Dulling’s wife contacted the NHS crisis team, operated by TEWV, as her husband needed help.

“Mrs Dulling ended the call frustrated at the lack of practical advice and assistance,” the coroner said.

Mr Dulling was deemed to present a risk of harm to himself and others when assed by the crisis team on August 28, 2023, the coroner said.

But, she added, the call “did not establish whether this risk had increased, such that Mental Health Act detention or other emergency intervention should be considered”.

It also did not offer “practical advice” to Mrs Dulling about taking her husband to hospital, calling an ambulance or “explain what assistance it was considered or anticipated could be provided by the police”.

The coroner said there was a risk of future deaths should this happen again.

In respect of the York Trust, Ms Cundy said there was “no evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs”, despite him “being deemed to lack capacity”.

The coroner raised further concern about a diet appropriate for Mr Dulling being “recorded and acted upon”.

There was evidence of a “delayed response by a staff nurse to the information that Mr Dulling was choking”, she added.

If this were to happen again, the coroner said, there was a risk of future deaths happening.

A York and Scarborough Teaching Hospitals NHS Foundation Trust spokesperson said: “The trust would like to convey sincere condolences to both families.

“We take the findings from both reports extremely seriously. We accept the coroner’s concerns and will respond within the required timescales. The trust's full response will be shared with the HM Coroner in due course. We are committed to act wherever necessary to improve patient safety.”

The Tees, Esk and Wear Valleys NHS Foundation Trust declined to comment.