South Yorkshire (West)
Coroner Area
Reports: 102
Earliest: Aug 2013
Latest: 2 Feb 2026
75% response rate (above 63% 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 (AI summary)
A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.
Noted
(AI summary)
The Royal College of Psychiatrists has invested in the development of a national consensus guideline on the neuropsychiatry of autoimmune conditions. This guidance, which will provide clinical red flag features, investigation strategies, and referral thresholds, is anticipated to be formally released within the next six months. The British Paediatric Neurology Association confirmed the lack of specific current guidelines on Autoimmune Encephalitis for children and young people. They expressed a willingness to be involved if a NICE Guideline were commissioned and highlighted delays in NMDA receptor antibody testing across the UK. The Department for Health and Social Care considers the concerns about national guidance on Autoimmune Encephalitis more appropriately addressed by NHS England and has advised that NHS England will provide a direct response.
Roger Leadbeater
All Responded
2026-0041
23 Jan 2026
Greater Manchester Police
South Yorkshire Police
Other related deaths
Concerns summary (AI summary)
Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a patient was lost, impacting leave decisions and risking public safety.
Action Taken
(AI summary)
• A new, purpose-designed form has been created to record the transfer of responsibility for a missing person.
• A mandatory task has been embedded within Compact, our MFH management system, providing officers with an automatic prompt at the relevant stage of the investigation and includes a direct link to the new form.
• A comprehensive communication has been circulated across the organisation, outlining the new process, the rationale for its introduction and the tragic circumstances that brought the issue to light.
Andrew Dodds
All Responded
2025-0587
17 Nov 2025
South Yorkshire Police Headquaters
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI 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.
Noted
(AI summary)
South Yorkshire Police have reviewed the concerns. They state that the s136 power is temporary and they engaged with the NHS trust. They are unable to make changes to the Police National Computer.
Mark Townsend
All Responded
2025-0512
13 Oct 2025
Sheffield Wednesday Football Club
Other related deaths
Concerns summary (AI summary)
Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future risk for timely emergency response.
Noted
(AI summary)
Sheffield Wednesday Football Club acknowledges the coroner's concerns, but emphasizes the robustness of their existing radio system and the positive findings of the inquest regarding their safety arrangements. They outline existing measures for steward training, communication, and system review.
Marcia Grant
All Responded
2025-0447
3 Sep 2025
Chief Executive, Rotherham Metropolitan…
Secretary of State for Education, Depar…
Other related deaths
Concerns summary (AI summary)
A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess risks to carers, led to an unsuitable child placement.
Action Planned
(AI summary)
The Department for Education will set out plans to significantly increase foster care numbers, backed by additional funding and investment in regional recruitment support hubs and a foster care retention model called Mockingbird. Rotherham Metropolitan Borough Council will continue to pursue their Looked After Children and Care Leavers Sufficiency Strategy, make improvements to documentation, recording and approval processes, and enhance risk assessment processes.
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 (AI 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
(AI summary)
SWYPT is reviewing intensive and assertive community support, updating referral pathways, and has included working with people with co-existing mental health problems and substance misuse issues as a priority area and has made the Public Health England eLearning course available to Trust staff.
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 (AI 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
(AI summary)
The practice created a new mental health template to standardize the procedure and coding in clinical records for mental health reviews and medication reviews, and reviewed patients taking SSRI medications. They have updated the process for future patients discharged from mental health services, and patients on medication receive annual/biannual medication reviews.
Christiana Dawson
All Responded
2024-0557
16 Oct 2024
Darnell Grange Nursing Home
Care Home Health related deaths
Concerns summary (AI 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
(AI summary)
Darnell Grange Nursing Home has updated its agency nurse induction to include istumble and post fall protocol, reinforced the policy of not moving a service user post fall until clinical assessments have been done, informed the agency of the breach of company policy regarding moving a service user after a fall, and checked that there are no changes in medication.
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 (AI 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 Planned
(AI summary)
Sheffield Health and Social Care will provide electronic copies of crisis assessments to the Neurology Department for service users known to them, include discharge summaries in annual record keeping audits, and establish a six-monthly shared learning forum with the Neurology Department.
Mavis Dewey
All Responded
2024-0435
7 Aug 2024
Monarch Health Care C/O Heeley Bank Car…
Care Home Health related deaths
Concerns summary (AI summary)
Agency staff's admitted failure to consistently read care plans jeopardises resident safety by hindering the provision of appropriate and individualised care.
Action Planned
(AI summary)
Monarch Healthcare is implementing a new clinical oversight form for moving and handling, monitoring staff via CCTV, auditing resident bedrooms for equipment, and requiring staff signatures at handover meetings, with implementation by August 31, 2024 and review by September 30, 2024.
Maureen Woollen
All Responded
2024-0335
19 Jun 2024
Deerlands Residential Home
Care Home Health related deaths
Concerns summary (AI 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
(AI summary)
Sheffcare has implemented a new Person-Centred Care system, provided refresher training to staff, updated policies, and performs audits, with oversight from the new Director of Quality and Care.
Jacob Shorter
All Responded
2024-0328
18 Jun 2024
Calderdale Council
Railway related deaths
Suicide (from 2015)
Concerns summary (AI 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 Planned
(AI summary)
The council plans to provide Independent Visitor volunteers with Mental Health First Aid Training where necessary, and to include a specific topic relating to suicide prevention and signs in the Induction Training programme.
Sophie Hindmarsh
All Responded
2024-0231
29 Apr 2024
Department of Health of Social Care
NHS England
West Yorkshire Integrated Care Board
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary)
A significant ambulance response delay was caused by severe hospital offloading delays, tying up vital resources and preventing timely emergency care.
Noted
(AI summary)
NHS England outlines actions taken to improve ambulance performance, including implementing the Delivery plan for recovering urgent and emergency care services, engaging with West Yorkshire ICB, and publishing the NHS Long Term Workforce Plan. These actions include joint escalation processes, investment in resources, and workforce enhancements. West Yorkshire ICB describes actions taken to reduce ambulance response times and handover delays, including funding for additional resource in call centres. The ICB also highlights the development of a System Coordination Centre (SCC) to enable a proactive system response to operational pressures. The DHSC acknowledges the concerns regarding ambulance response times and hospital handover delays, notes that West Yorkshire ICB and NHS England will respond directly on specific actions, and highlights national initiatives to improve urgent and emergency care performance.
Erik Marshall
All Responded
2024-0222
25 Apr 2024
Cheshire and Merseyside Integrated Care…
Child Death (from 2015)
Suicide (from 2015)
Concerns summary (AI 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 Planned
(AI summary)
The Cheshire and Merseyside ICB intends to commission Occupational Therapy services for children and young people up to the age of 18 years and 364 days, which will be in place from December 2024.
Matthew Terrill
All Responded
2024-0176
27 Mar 2024
South Yorkshire Police Headquarters
Alcohol, drug and medication related deaths
Concerns summary (AI 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 Planned
(AI summary)
South Yorkshire Police will review the booking in sheet, create posters for holding areas, and design force screen savers to remind officers of information needed during booking in. This will be supported by a yearly CPD package.
Saffra Winn
All Responded
2024-0173
27 Mar 2024
Sheffield City Council
Other related deaths
Concerns summary (AI 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
(AI summary)
Sheffield City Council has instigated a new procedure and reporting framework to log all reported fatalities and near misses from falls from high rise council accommodation, and is establishing a High-Rise Forum with window safety as an agenda item. They have also written to all residents in high-rise accommodation outlining window safety best practice.
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 (AI 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
(AI summary)
Sheffield Teaching Hospitals NHS Foundation Trust and Sheffield Children’s Foundation Trust have agreed a Cross Trust Transition pathway, detailing the process followed by both organisations, including the sharing of local transfer documentation and appropriate healthcare records. The South Yorkshire & Bassetlaw Acute Federation Trust Paediatric Innovator Programme was established, which includes a project on standardising developmentally appropriate healthcare for young people transitioning from paediatric to adult secondary care.
Jean Walker
All Responded
2024-0158Deceased
20 Mar 2024
Department of Health and Social Care
West Yorkshire Integrated Care Board
Emergency services related deaths (2019 onwards)
Concerns summary (AI 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
(AI summary)
West Yorkshire ICB describes several actions already taken, including increasing ambulance capacity through additional vehicles and staff, improving the Emergency Operation Centre, developing a System Coordination Centre, and improving referral processes to alternative care pathways. The Department of Health and Social Care notes that NHS England is investing in additional ambulance crews and clinical workforce, and working to address handover delays. They also cite the 'Delivery plan for recovering urgent and emergency care services' and note improvements in ambulance response times.
Darnell Smith
All Responded
2024-0149
18 Mar 2024
Royal Hallamshire Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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
(AI summary)
To improve access to Individualised Care Plans (ICPs) for sickle cell patients, Sheffield Teaching Hospitals has started filing a copy of the ICP in the front of the patient’s paper record and introduced a new standard operating procedure. They have also developed an action card and delivered training to 50 Haematology nursing staff (with 33 more planned) and Emergency Department staff. The ICP will be recorded directly into the documents section of the new EPR, with an alert showing when staff opens the patient's record.
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 (AI 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 Planned
(AI summary)
The Barnsley IHBTT will share the coroner's concerns with practitioners, emphasizing the importance of referring to the resource pack for mental health support services. When a referral to BSARC is declined, the service will reconsider the suitability of advice given and review treatment plans.
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 (AI 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
(AI summary)
Sheffield Children's NHS Foundation Trust has implemented new processes to ensure Care Groups are fully sighted on complaints, implemented 'Safety Wednesday' led by the Medical Director and Chief Nurse, and refreshed Freedom to Speak Up training.
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 (AI 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 Planned
(AI summary)
Sheffield Health and Social Care NHS Foundation Trust is commissioning a new clinical record keeping policy and training, aiming for completion by May 2024 with training rollout from June 2024, alongside a clinical audit programme. They will also issue a Blue Light Learning Notice to staff regarding timely and accurate record keeping. Sheffield Health & Social Care NHS Foundation Trust has implemented several changes including instructing Responsible Clinicians to capture diagnoses in the electronic patient record, reviewing the format of discharge summaries, implementing a tool to support clinicians in using patient records, and rolling out a new clinical record keeping training package.
Adam Johnson
All Responded
2023-0427
3 Nov 2023
Elite Ice Hockey League
English Ice Hockey
Horwich Farrelly Limited
+1 more
Other related deaths
Concerns summary (AI 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.
Noted
(AI summary)
England Ice Hockey along with Ice Hockey UK (IHUK) and Scottish Ice Hockey (SIH), confirm the mandating of neck laceration protectors which comes into effect from 1st January 2024. The EIHL will mandate the use of neckguards for all players from 1 January 2024 in training and games, and a temporary rule change has been put in place to sanction non-compliance pending the provision of the full rule change from the IIHF. Ice Hockey UK describes its role as the national governing body and notes that the IIHF has mandated neck guards at all levels of competition. They state that IHUK mandated neck guards for Senior Men and Women with immediate effect on 30 October 2023, in addition to the existing mandate for the U16, U18 and U20 categories. England Ice Hockey provides information about regulations around neck laceration protection and the governance structure of Ice Hockey in the UK, but does not commit to specific actions beyond what is already recommended.
Alex Dews
All Responded
2023-0380
10 Oct 2023
Department for Education
Department of Health and Social Care
Other related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Outwood Grange Academies Trust details the mental health and wellbeing services involved with the academy, referral processes, and discharge procedures. They note that further guidance from the DfE on support in schools for pupils who are transgendering is still awaited. The DfE is working with the Minister for Women and Equalities to develop guidance to support schools and colleges in relation to children who are questioning their gender, with a public consultation planned before publication. The Department of Health and Social Care outlines NHS England's plans to increase access to community mental health services for children and young people, and to implement new access and waiting time standards. They also describe NHS England's overhaul of children’s gender identity services following recommendations from Dr. Cass.
Mark Bennett
All Responded
2023-0456
19 Sep 2023
Association of Ambulance Chief Executiv…
Yorkshire Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary (AI 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 Planned
(AI summary)
YAS will review and update its clinical documentation and include decisions on terminating resuscitation attempts in annual clinical refresher training. AACE is engaged with a National Institute for Health Research study, which may lead to an update to JRCALC guidance regarding termination of resuscitation.