South Yorkshire (West)
Coroner Area
Reports: 102
Earliest: Aug 2013
Latest: 2 Feb 2026
73% response rate (above 62% average).
Mia Lucas
All Responded
2026-0070
2 Feb 2026
NHS England
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.
Action taken summary
The Royal College of Psychiatrists has established a national expert working group that has developed national guidance on the neuropsychiatric presentation of autoimmune encephalitis and autoimmune p
Andrew Dodds
All Responded
2025-0587
17 Nov 2025
South Yorkshire Police Headquaters
Mental Health related deaths
Suicide (from 2015)
Concerns summary
Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 detention was missing from police systems, preventing mental health service contact.
Action taken summary
South Yorkshire Police has implemented a new Standard Operating Procedure (SOP) and developed enhanced briefings for officers regarding the transfer of individuals detained under Section 136 of the Me
Mark Townsend
All Responded
2025-0512
13 Oct 2025
Sheffield Wednesday Football Club
Other related deaths
Concerns summary
Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future risk for timely emergency response.
Action taken summary
Sheffield Wednesday Football Club disputes that the brief delay in radio communication indicates an unsafe system, noting the inquest found no causative failings. They state they will continue existin
Claire Driver
All Responded
2025-0161
24 Mar 2025
South West Yorkshire Partnership NHS Fo…
Community health care and emergency services related deaths
Mental Health related deaths
Concerns summary
Mental health teams exhibited inadequate assertive engagement and poor police liaison for a deteriorating patient, compounded by a lack of mandatory staff training on substance misuse and mental health.
Action taken summary
The Trust has developed and made operational an Intensive Community Support Team for assertive engagement, updated its clinical risk assessment and management policy, and enhanced liaison with the pol
David Stables
All Responded
2024-0676
6 Dec 2024
Dearne Valley Group Practice
Community health care and emergency services related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary
There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns about whether these essential reviews were conducted or adequately documented.
Action taken summary
The practice has already implemented a new mental health template and standard operating procedure for clinicians to accurately record mental health and medication reviews. They have also reviewed all
Christiana Dawson
All Responded
2024-0557
16 Oct 2024
Darnell Grange Nursing Home
Care Home Health related deaths
Concerns summary
Agency nurses were not provided with essential care home-specific training or policies, leading to an unsafe presumption they would know not to move a resident after a fall.
Action taken summary
Darnall Grange Nursing Home has secured access to System One for medication review and is now using it monthly. They have updated the agency worker induction checklist to include fall …
Bryan and Mary Andrews
All Responded
2024-0532
4 Oct 2024
Sheffield Health and Social Care NHS Fo…
Mental Health related deaths
Other related deaths
Concerns summary
A severe lack of communication and coordination between multiple health services resulted in significant delays, repeated referral rejections, and missed opportunities for treatment for a patient with complex epilepsy and psychotic symptoms.
Action taken summary
The Trust's Single Point of Access Service is no longer operational due to a transformation programme. They plan to ensure neurology departments receive electronic copies of crisis assessments for sha
Mavis Dewey
All Responded
2024-0435
7 Aug 2024
Monarch Health Care C/O Heeley Bank Car…
Care Home Health related deaths
Concerns summary
Agency staff's admitted failure to consistently read care plans jeopardises resident safety by hindering the provision of appropriate and individualised care.
Action taken summary
Monarch Healthcare has immediately implemented new inductions for all agency staff, including a care plan comprehension assessment before working, and all Monarch employees now complete an annual asse
Maureen Woollen
All Responded
2024-0335
19 Jun 2024
Deerlands Residential Home
Care Home Health related deaths
Concerns summary
The care home failed to conduct a falls risk assessment on admission and did not promptly seek medical attention for injuries. Care notes were inadequately used to record incidents or monitor injury progression.
Action taken summary
Sheffcare has implemented changes, including a new Person-Centred Care system for recording injuries and incidents, and staff have received refresher training. A new policy ensures a complete falls ri
Jacob Shorter
All Responded
2024-0328
18 Jun 2024
Calderdale Council
Railway related deaths
Suicide (from 2015)
Concerns summary
Crucial information about previous suicidal ideation was not shared with foster carers. Calderdale Council lacks clear training and escalation routes for mental health concerns, creating a risk of future deaths.
Action taken summary
Calderdale Council disputes the necessity of the PFD report, stating their Independent Visitor service adheres to existing safeguarding guidance. However, as a direct result of the incident, they plan
Sophie Hindmarsh
All Responded
2024-0231
29 Apr 2024
West Yorkshire Integrated Care Board
Department of Health of Social Care
NHS England
Emergency services related deaths (2019 onwards)
Concerns summary
A significant ambulance response delay was caused by severe hospital offloading delays, tying up vital resources and preventing timely emergency care.
Action taken summary
NHS England prioritized improving ambulance performance in 2023/24 through a national delivery plan, resulting in substantial improvements in response and handover times, and worked to eliminate 12-ho
Erik Marshall
All Responded
2024-0222
25 Apr 2024
Cheshire and Merseyside Integrated Care…
Child Death (from 2015)
Suicide (from 2015)
Concerns summary
A significant commissioning gap leaves high-risk 17-year-olds without essential sensory occupational therapy, as child services end at 16 and adult services only accept from 18.
Action taken summary
NHS Cheshire & Merseyside Integrated Care Board recognises the commissioning gap for Occupational Therapy services for 16-18 year olds and intends to commission this service to cover young people up …
Saffra Winn
All Responded
2024-0173
27 Mar 2024
Sheffield City Council
Other related deaths
Concerns summary
Sheffield City Council failed to conduct risk assessments for high-rise windows after two fatalities and lacks formal procedures for investigating and assessing risks following catastrophic incidents in social housing.
Action taken summary
Sheffield City Council has instigated a new procedure and reporting framework for high-rise fatalities and near misses from falls, including guidance for window safety reports, which will be in place
Matthew Terrill
All Responded
2024-0176
27 Mar 2024
South Yorkshire Police Headquarters
Alcohol, drug and medication related deaths
Concerns summary
Police officers lack sufficient training to recognise drug intoxication, overdose, mental health conditions, and the heightened risk of positional asphyxia in detainees. There's also no mandatory refresher training for constant observations.
Action taken summary
South Yorkshire Police has tasked its Custody Training Manager to review current training and plans to add new content on drug intoxication, mental health conditions, and positional asphyxia to Custod
Craig Burfield
All Responded
2024-0181
26 Mar 2024
Sheffield Children’s NHS Foundation Tru…
Sheffield Teaching Hospital Trust NHS F…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
There is currently no established adult care pathway, transition protocol from childhood to adulthood, or effective review process for patients with hydrocephalus shunts, risking fatal outcomes.
Action taken summary
Sheffield Teaching Hospitals and Sheffield Children’s Foundation Trust have jointly agreed and implemented a Transition Policy and a Cross Trust Transition Pathway, supported by specialist transition
Jean Walker
All Responded
2024-0158Deceased
20 Mar 2024
West Yorkshire Integrated Care Board
Department of Health and Social Care
Emergency services related deaths (2019 onwards)
Concerns summary
An ambulance service failed to meet response targets for a Category 2 call, exacerbated by significant hospital offloading delays that tied up vital resources.
Action taken summary
West Yorkshire ICB has invested £33.2m since 2021/22, increasing Yorkshire Ambulance Service staff by 839 FTE and clinical staff in the Emergency Operations Centre by 13%. They have implemented an …
Darnell Smith
All Responded
2024-0149
18 Mar 2024
Royal Hallamshire Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A crucial individualised care plan was difficult to find and not used during the patient's admission, despite being flagged, risking inadequate care.
Action taken summary
Sheffield Teaching Hospitals has introduced a new Standard Operating Procedure for Individualised Care Plans (ICPs), now files hard copies in patient records, and developed a Sickle Cell Disease Actio
Rachel Mortimer
All Responded
2024-0036
20 Jan 2024
South West Yorkshire Partnership Trust
Alcohol, drug and medication related deaths
Suicide (from 2015)
Concerns summary
The family received no support options for a relative's mental state, and no alternative risk mitigation service was provided when the intended one was unavailable.
Action taken summary
The Trust will share the coroner's concerns with all Barnsley IHBTT practitioners to emphasize referring to resource packs for advising families on support services. It has also agreed that if …
Kyra Aslam
All Responded
2023-0498
5 Dec 2023
Sheffield Children’s NHS Foundation Tru…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A culture exists where medics may disregard parents' or nurses' views, and junior doctors are not adequately educated when consultants override their decisions, hindering learning.
Action taken summary
The Trust has implemented several new processes including a 'How We Listen Policy', 'Safety Wednesday' incident reviews, and a new Patient Safety Incident Response Framework. They have also rolled out
Gareth Etchells-Height
All Responded
2023-0517
20 Nov 2023
Sheffield Health and Social Care Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Failures in discharge planning, inconsistent medical note review, outdated risk assessments, and poor record-keeping without audit systems led to fragmented care and a lack of understanding of the patient's condition.
Action taken summary
The Trust is reinforcing the importance of accurate diagnoses in discharge reports and reviewing their format. They are developing new policies and a robust training programme for risk assessments and
Adam Johnson
All Responded
2023-0427
3 Nov 2023
English Ice Hockey
Ice Hockey UK
Other related deaths
Concerns summary
The International Ice Hockey Federation does not mandate neck guards for adult players, raising concern that this lack of required protective equipment could lead to future deaths.
Action taken summary
England Ice Hockey, Ice Hockey UK, and Scottish Ice Hockey have mandated the wearing of neck laceration protectors for all players and coaches in all forms of ice hockey in …
Alex Dews
All Responded
2023-0380
10 Oct 2023
Department of Health and Social Care
Department for Education
Other related deaths
Concerns summary
School avoided NHS mental health referrals due to excessive waiting lists, instead procuring private support with unclear allocation processes and poor communication between the school and external providers.
Action taken summary
The academy has allocated a key member of the Inclusion team to manage all external referrals for mental health support. They plan to provide training on new referral flow-charts and …
Mark Bennett
All Responded
2023-0456
19 Sep 2023
Yorkshire Ambulance Service
Association of Ambulance Chief Executiv…
Emergency services related deaths (2019 onwards)
Concerns summary
Paramedics lack clear guidance and protocols on the appropriate duration of resuscitation efforts and criteria for hospital transport for thrombolysis, placing patients at risk.
Action taken summary
Yorkshire Ambulance Service plans to review and update its clinical documentation regarding decisions on terminating resuscitation attempts, and will include this topic as part of annual clinical refr
Lee Dryden
All Responded
2025-0402
2 Aug 2023
NHS England
Department of Health and Social Care
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
NHS Trusts lack understanding of guidance for external image reporting, and the ambulance service experienced significant delays in responding to a category 2 call due to high escalation and hospital handover issues.
Action taken summary
NHS England has published recommendations (October 2022) and hosted a national webinar (March 2023) on imaging report sharing to improve processes across Trusts. They also published a delivery plan (J
June Peel
All Responded
2025-0403
11 Jul 2023
Belle Green Court Care Home
Care Home Health related deaths
Concerns summary
Failures in documenting injuries, inadequate handover of critical information, and staff not following care plans led to a patient with a femur fracture receiving inappropriate care without timely medical attention.
Action taken summary
Belle Green Court Care Home has provided staff with updated training on care planning, record keeping, and manual handling, and all staff have reviewed key policies and procedures. They have …