South Yorkshire (West)
Coroner Area
Reports: 102
Earliest: Aug 2013
Latest: 2 Feb 2026
75% response rate (above 63% average).
Tracy Gambrill
Partially Responded
2023-0405
24 Oct 2023
NHS England
General Medical Council
Royal College of Surgeons of England
+1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Surgical procedures for this operation rely on anatomical landmarks without sufficient intra-operative measurement, leading to excessively deep incisions and potential safety risks.
Noted
(AI summary)
The Society of British Neurological Surgeons has written to all SBNS members, asking them to recognise the importance of measuring depth intraoperatively, and empowering them to abort surgery when findings are not consistent with expectations. The GMC acknowledges the concerns but refers them to NICE, medical royal colleges, or specialty bodies, as they do not provide guidance on specific clinical procedures. They highlight their role in setting professional standards and supporting doctors to meet them.
Norma Kyte
Partially Responded
2023-0398
12 Oct 2023
Broomcroft House Nursing Home
BUPA
Care Home Health related deaths
Concerns summary (AI summary)
Undersized sensory mats next to beds fail to detect patient movement if they fall outside the mat's small coverage area, risking undetected falls and potential non-compliance with manufacturer instructions.
Action Taken
(AI summary)
Bupa has taken several actions including reviewing the falls prevention policy, implementing mandatory sensor mat training, adding sensor mats to the equipment catalogue with recommended uses, ensuring sensor mat use is clearly recorded in care plans and providing 1:1 sessions with staff to reinforce the importance and correct use of the equipment.
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.
Lee Dryden
All Responded
2025-0402
2 Aug 2023
Department of Health and Social Care
NHS England
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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
(AI summary)
NHS England highlights actions taken including publishing recommendations regarding alerts and notification of imaging reports, hosting a national webinar, and noting that the RCR will review guidance. They are also focusing on improving ambulance performance as part of a delivery plan. DHSC notes actions taken by NHS England to clarify guidance around imaging reports, and additional funding to expand ambulance capacity and improve response times. They also highlight measures to improve patient flow and bed capacity within hospitals.
June Peel
All Responded
2025-0403
11 Jul 2023
Belle Green Court Care Home
Care Home Health related deaths
Concerns summary (AI 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
(AI summary)
Staff at Belle Green Court Care Home have received updated training on care planning and record keeping, and reviewed key policies and procedures. The Manager has commenced a tracker of all accidents and incidents to assist identifying any patterns or concerns.
Mark Ravensdale
All Responded
2025-0400
16 May 2023
South West Yorkshire Partnership NHS Fo…
Suicide (from 2015)
Concerns summary (AI summary)
Mental health services failed to directly engage with the deceased to properly and adequately assess his mental health condition.
Action Planned
(AI summary)
The Trust will develop and implement a triage checklist for their Single Point of Access (SPA) teams, with an initial study of its impact undertaken after 6 months of implementation. This is in response to concerns about direct contact with individuals during triage.
Mojeri Adeleye
All Responded
2025-0401
10 May 2023
Sheffield Teaching Hospitals NHS Founda…
Child Death (from 2015)
Concerns summary (AI summary)
There was a lack of regard for the mother's pregnancy knowledge and insufficient discussion with parents about potential measures for premature labour before 22 weeks.
Action Taken
(AI summary)
Sheffield Teaching Hospitals NHS Foundation Trust has revised its policies to ensure due dates are checked, included human factors in mandatory training, and is working with the Yorkshire and Humber Joint Maternity Clinical Forum to standardise pathways of care. They have also introduced twice-daily multidisciplinary ward rounds and included specific training regarding the management of extreme prematurity in their Bereavement Study Day.
James Philliskirk
All Responded
2023-0376
10 May 2023
Sheffield Children’s NHS Foundation Tru…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Junior staff failed to escalate concerns, exacerbated by unclear guidance on chickenpox reinfection, confirmation bias, and inadequate assessment of skin lesions. GP referrals were also not given sufficient weight, delaying crucial treatment.
Noted
(AI summary)
Sheffield Children's NHS Foundation Trust CEO expressed apologies to the family and outlined the various actions taken, including a meeting with the family and a presentation to the Trust Board to emphasize learnings from the case. Sheffield Children's NHS Foundation Trust has improved induction training for junior doctors, providing information on when to escalate concerns to senior staff, particularly regarding reattenders, fever, chicken pox and sepsis. They have reminded primary care of the current referral system and will ensure patients arriving with GP letters are seen by the appropriate team.
Margaret Russell
Historic (No Identified Response)
2022-0374
22 Nov 2022
Barnsley District General Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The decision not to commence CPR was contrary to both Trust and National Policy, potentially impacting patient outcomes.
Joan Rossington
Historic (No Identified Response)
2022-0373
22 Nov 2022
Sheffield Teaching Hospitals NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
External care staff supporting the patient on the ward were excluded from risk assessments and care plans, leading to potential delivery of conflicting care and an unsafe environment.
Daniel Lee
All Responded
2022-0372
21 Nov 2022
NHS South Yorkshire Integrated Care Boa…
South Yorkshire West NHS Foundation Tru…
Suicide (from 2015)
Concerns summary (AI summary)
A lack of a key worker approach led to superficial risk assessments and professional relationships. Communication with both the armed forces and the family was inadequate, hindering effective risk sharing and support.
Noted
(AI summary)
The Trust offers condolences and provides context on Intensive Home-based Treatment Teams (IHBTT), clarifying their role and approach to risk assessment, particularly regarding communication with family members. They state that the partner's contact was appropriately considered and shared with the visiting practitioner.
Roy Middleton
Historic (No Identified Response)
2022-0369
17 Nov 2022
International Academies of Emergency Di…
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary)
The emergency dispatch algorithm fails to account for anticoagulant medication in head injury cases, risking delayed appropriate responses and future deaths.
Chelsea Mooney
All Responded
2022-0259
18 Aug 2022
Cygnet Health Care
NHS England
Community health care and emergency services related deaths
Concerns summary (AI summary)
The diagnostic process lacked professional curiosity and critical review of patient disclosures, leading to unverified information influencing care. Crucial information sharing with family was inadequate, and self-harm incidents lacked debriefs to inform future risk assessments.
Action Taken
(AI summary)
NHS England's Case Manager attended weekly meetings at Cygnet Hospital Sheffield, and this included discussions about Chelsea’s care. The revised NHSE Case Management Standard Operating Procedure and the in-patient quality programme will strengthen the importance of engagement with families and carers. Cygnet has taken several actions, including reviewing and improving policies and training related to risk assessment, observations, and communication. They have also implemented enhanced governance and oversight processes, including safety huddles and regular audits, to identify and address risks.
Brian Parry
Historic (No Identified Response)
2022-0234
28 Jul 2022
Brunswick Retirement Village
Care Home Health related deaths
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary)
Staff lacked training to immediately call emergency services and were not confident in basic first aid; emergency assistance calls were inefficiently routed, and no advanced first aider was on site.
Ann Pickering
All Responded
2022-0206
4 Jul 2022
Barnsley District General Hospital and …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Delays occurred in both accepting transfer to hospital and inserting a necessary NG tube. There was a lack of clear policies and procedures for transferring patients under section, including required documentation.
Action Planned
(AI summary)
Barnsley Hospital and South West Yorkshire Partnership are improving communication and referral processes, clarifying roles and responsibilities, and creating a protocol detailing operational delivery of a safe pathway, including clarifying consent and treatment responsibilities.
Marjorie Grayson
All Responded
2022-0146
16 May 2022
Ministry of Justice
Sheffield Health and Social Care NHS Fo…
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Other related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The patient's discharge plan disregarded clear clinical advice regarding her high suicide risk and risk to family, leading to her returning home alone. There was also a failure to integrate recommendations from previous criminal justice proceedings.
Noted
(AI summary)
Sheffield Health & Social Care NHS Foundation Trust outlines a plan to develop a protocol for working with older adults with a forensic history, ensure thorough risk assessments when removing a service user from detention, improve communication with service users and families, ensure complex clinical decisions are multidisciplinary, and deliver online training on the Mental Health Act. The Government Legal Department, on behalf of the Probation Service, acknowledges the concerns but states it's a matter for the sentencing Judge to determine Restriction Orders. They will obtain the Court transcript of Mrs Grayson's sentencing hearing and share concerns with the Ministry of Justice colleagues in the Mental Health Caseworker team.
Jamie Bennett
Response Pending
2022-0136
Practice Plus Group
The Ministry of Justice, Justice and De…
Alcohol, drug and medication related deaths
State Custody related deaths
Concerns summary (AI summary)
Lack of clear instructions for welfare checks, unclear task responsibility for agency night staff, and absent audit processes risk inadequate patient supervision and future deaths.
Action Taken
(AI summary)
Practice Plus Group has updated its Naloxone disclaimer form to clarify risks of refusal and revised its information-sharing process for patients discharged from HMP Moorlands, implementing new clinical handover templates and quality assurance for discharge summaries.
Millie-Rae Needham
Historic (No Identified Response)
2022-0122
25 Apr 2022
Sheffield Teaching Hospitals NHS Founda…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report identifies concerns that a midwife was talked out of seeking support for an episiotomy, leading to delays and inadequate monitoring, and that there was a lack of discussion with the patient about birthing options prior to labour.
Cassian Curry
All Responded
2022-0120
25 Apr 2022
Sheffield Teaching Hospitals NHS Founda…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Parents were not informed of a critical consultant plan for a central line review. Concerns also include a lack of consideration for national form suitability and how regional support is accessed for highly vulnerable babies.
Action Taken
(AI summary)
The Trust is working with the South Yorkshire Neonatal Operational Development Network to deliver a network-wide action plan for increased family involvement in neonatal care, and the updated umbilical line insertion checklist now includes a specific entry requirement for informing parents if the catheter is in a suboptimal position.
Joshua Rennard
Historic (No Identified Response)
2022-0091
7 Mar 2022
Sheffield Health and Social Care NHS Fo…
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at risk of harm and death.
Jack Ritchie
Historic (No Identified Response)
2022-0072
7 Mar 2022
Department for Culture, Media and Sport
Department for Education
Department of Health and Social Care
Community health care and emergency services related deaths
Other related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The report identifies that the system of regulation did not prevent the deceased from gambling when addicted, warnings were insufficient, and training for medical professionals on gambling addiction was lacking, particularly for GPs.
Brian Rochell
Historic (No Identified Response)
2021-0229
7 Jul 2021
Sheffield Teaching Hospitals NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Concerns about an individual's professional practice were not referred to the relevant professional body in a timely manner. This delay in addressing competence issues poses a risk to future patients.
Laura Booth
All Responded
2021-0137
5 May 2021
Sheffield Teaching Hospitals NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Senior clinicians and staff displayed a grave lack of understanding and application of the Mental Capacity Act, with inadequate training leading to failures in best interests decision-making and patient/family involvement.
Action Taken
(AI summary)
The Trust has taken several actions to improve Mental Capacity Act (MCA) understanding, including enhanced MCA training, clearer documentation guidelines, and Health Passport promotion. They also reviewed the verification of death process and found the documentation to be accurate based on the patient's condition at the time of death.
Anthony Wilkinson
All Responded
2021-0102
13 Apr 2021
Stars Social Support Ltd, Care Quality …
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Other related deaths
Concerns summary (AI summary)
The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied on an insecure WhatsApp group for critical service user information.
Action Taken
(AI summary)
The Trust has amended its Level 6 food consistency advice sheets by removing picture anomalies and amending statements to remove ambiguity, based on IDDSI Framework reviewed in May 2021. CQC has reviewed the concerns raised, contacted Stars Social Support Limited, and referred the report to CQC's policy team to review. The shorter report guidance was implemented in January 2019. The organisation has ceased trading and is liaising with the Local Authority and CQC to transfer service users.