South Yorkshire East

Coroner Area
Reports: 63 Earliest: Aug 2013 Latest: 17 Mar 2026

75% response rate (above 63% average).

Response Status
Responded 47 Historic 16
AI Classification
Action Taken 33%
Action Planned 44%
Noted 21%
Disputed 2%
Based on 57 classified responses
Top Categories
Hospital Death (Clinical Procedure… (31) Suicide (from 2015) (8) Community health care and emergenc… (8) State Custody related deaths (8) Mental Health related deaths (5)
Quarterly Trend
Category Breakdown
How does this area compare?
vs Yorkshire and the Humber average: +3 reports · +13pp response rate
vs national average: -21 reports · +12pp response rate
63 results
William Bows
All Responded
2015-0301 28 Jul 2015
Northern General Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The report identifies a lack of protocols for advising primary care providers on monitoring patients prescribed Amiodarone, specifically concerning liver function, thyroid tests, and respiratory difficulties.
Action Taken (AI summary) Sheffield Teaching Hospitals NHS Trust states that an appropriate policy was in place at the time of the prescription of amiodarone and that this was followed during the inpatient stay and communicated to the GP. Since this case, but not because of it, an Amiodarone Passport and Patient Handheld Information Booklet has been developed which provides information about the drug, including the monitoring regime and the potential life-threatening side effects.
Isabella Drew
All Responded
2015-0289 16 Jul 2015
Department of Health and Social Care NHS England
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate national guidance and audit procedures prevent healthcare providers from consistently advising pregnant women about whooping cough vaccination. Poor communication links between antenatal healthcare providers also pose risks.
Noted (AI summary) The Department of Health acknowledges the coroner's concerns regarding advice and support for pregnant women about whooping cough vaccination. They note that NHS England is responding on behalf of the Department of Health, Public Health England and NHS England. NHS England will consider the coroner's concerns about integrating pertussis and immunisation services into routine maternity care as part of an independent review of maternity services in England. Public Health England also manages the situation as a national level incident.
Phyllis Broomhead
All Responded
2015-0290 6 Jul 2015
Rotherham Metropolitan Borough Council
Care Home Health related deaths
Concerns summary (AI summary) Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a systemic gap in monitoring high-risk residents when nursing care isn't deemed necessary, leaving them vulnerable.
Action Planned (AI summary) Rotherham Metropolitan Borough Council will provide a detailed action plan regarding recommendations made under Regulation 28, outlining actions taken, actions to be achieved, and timescales to conclude any uncompleted actions.
James Savo
Historic (No Identified Response)
2015-0209 1 Jun 2015
Rotherham, Doncaster and South Humber N…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Effective communication systems between families/carers and staff are not routinely followed or audited, and understanding of early discharge plans is inconsistent, hindering seamless patient transitions.
Colin Tyson
All Responded
2015-0080 4 Mar 2015
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns were raised about GPs' interpretation of patient confidentiality, which may prevent family members from sharing vital information about vulnerable individuals at risk of suicide.
Action Planned (AI summary) NHS England, working with NHS Wakefield CCG, has developed an advice sheet for GP practices on responding to third-party concerns about patients, which will be shared across Wakefield and Yorkshire and the Humber. This information will also form part of safeguarding training for practices.
David Bladen
All Responded
2015-0079 4 Mar 2015
National Institute for Health and Care …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is an absence of clear guidance for optimal thromboprophylaxis management in patients with restricted mobility due to braces, but not in casts.
Noted (AI summary) NICE acknowledges the coroner's concerns about a lack of national guidance on VTE prophylaxis for patients in lower limb braces. NICE's clinical guideline (CG92) on VTE recommends mechanical VTE prophylaxis be continued until the patient no longer has significantly reduced mobility. They note that the guideline is to be updated and a new scope will be prepared as part of the process.
Margaret Clarke
All Responded
2015-0046 9 Feb 2015
Doncaster Borough Council Health and Safety Executive
Other related deaths
Concerns summary (AI summary) There is a lack of guidance for the effective cleaning of fixed shower heads, which are increasingly common in private and public leisure facilities.
Noted (AI summary) The HSE states it has no enforcement powers under the General Product Safety Regulations regarding showerheads and has passed the coroner's letter to the local Trading Standards Department. The council explains its duties under the Consumer Protection Act and General Product Safety Regulations, noting the absence of specific regulations for showerheads. They suggest the HSE review guidance regarding Legionnaires' disease and shower systems.
Zakariyya Clark
Historic (No Identified Response)
2014-0440 7 Oct 2014
Doncaster and Bassetlaw NHS Foundation …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant deficiencies in A&E patient assessment and documentation, including vital signs and injury details, posed a risk to future patients if not addressed by system enhancements.
Peter Hinchliffe
Historic (No Identified Response)
2014-0284 25 Jun 2014
BMI Hospital Thornbury Department of Health and Social Care NHS England +1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant delays in diagnostic investigations across both private and NHS sectors, coupled with inconsistent advice and management for young athletes experiencing syncope, pose a continuing risk.
Elizabeth Turnbull
Historic (No Identified Response)
2014-0035 24 Jan 2014
British Industrial Truck Association HM Principle Specialist Inspector
Other related deaths
Concerns summary (AI summary) The close proximity of thumbwheel controls, coupled with the absence of dual controls, increased the risk of inadvertently releasing locking pins for excavator attachments.
Daniel Williams
All Responded
2014-0009 6 Jan 2014
Rotherham, Doncaster and South Humbersi…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for key patient information.
Action Taken (AI summary) The Trust has implemented a patient record development programme which provides alerts to staff, states a patient centred approach, and has rolled out training for staff and improved patient handovers. They also state to have developed guidance for staff and patients to provide detailed information.
Rosemary Brownyn Ferguson
Historic (No Identified Response)
2013-0365 12 Dec 2013
Doncaster and Bassetlaw Teaching Hospit…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Poor communication between hospital staff and Social Services led to a discharge without support. Unclear instructions given to a friend regarding patient care, combined with scanty hospital notes, created significant misunderstandings and risks.
David George White
Historic (No Identified Response)
2013-0172 1 Aug 2013
Regeneration and Environment
Road (Highways Safety) related deaths
Concerns summary (AI summary) The coroner requests consideration of specific measures to reduce road traffic injuries at or on the approach to a bend on the A19 at Owston.