South Yorkshire (West)

Coroner Area
Reports: 102 Earliest: Aug 2013 Latest: 2 Feb 2026

73% response rate (above 62% average).

Response Status
Responded 74 No Response 1 Historic 25
AI Classification
Action Taken 75%
Action Planned 12%
Noted 6%
Disputed 6%
Based on 16 classified responses
Top Categories
Hospital Death (Clinical Procedure… (36) Other related deaths (18) Community health care and emergenc… (15) Suicide (from 2015) (11) Child Death (from 2015) (10)
Quarterly Trend
Category Breakdown
How does this area compare?
vs Yorkshire and the Humber average: +42 reports · +12pp response rate
vs national average: +19 reports · +11pp response rate
102 results
Thomas Rawnsley
All Responded
2020-0283 9 Dec 2020
NHS England Yorkshire Ambulance Service
Community health care and emergency services related deaths Emergency services related deaths (2019 onwards) Other related deaths
Concerns summary Virtual consultations risk misunderstanding due to lack of written follow-up. Inconsistent initial questioning across emergency services leads to incomplete clinical triage, and paramedic patient leaflet information is often inaccurate.
Carolyne Senior
All Responded
2020-0231 11 Nov 2020
Barnsley Hospital NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Hospital staff lacked sufficient specialist mental health advice to properly assess and mitigate falls risks for patients with mental health needs, leading to inadequate care plans.
Emily Greene
All Responded
2020-0288 6 Oct 2020
South Yorkshire Police HQ
Police related deaths Suicide (from 2015)
Concerns summary Failures in police investigation of a sexual assault included employing untrained officers, mishandling referrals, poor victim communication, and inadequate facilities, compounded by mishandling a missing person's report.
Eileen Pollard
Historic (No Identified Response)
2020-0053 3 Mar 2020
Crown Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't recorded, potentially endangering patients if call bells are non-functional.
Joan Howard
All Responded
2021-0007 10 Feb 2020
Sheffield Teaching Hospitals NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate adherence to specialist nutritional guidelines, including providing inappropriate food and failing to escalate concerns, coupled with a lack of thickener for fluids, contributed to patient neglect.
Sandra Scott
Historic (No Identified Response)
2019-0374 6 Nov 2019
Upwell Street Surgery Sheffield Clinical Commissioning Group NHS Digital +1 more
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A GP system flaw prevented a patient from receiving prescribed medication, and hospital staff failed to act on critical test results for a discharged patient, both contributing to preventable death.
Arthur Jepson
All Responded
2019-0300 16 Sep 2019
Yorkshire Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary High resource pressure resulted in a missed two-hour review of an emergency call, preventing re-categorisation and potentially impacting outcomes in future cases.
John Gogarty
Historic (No Identified Response)
2019-0200 17 Jun 2019
National Probation Service RDaSH NHS Trust
Mental Health related deaths
Concerns summary A mental health trust failed to follow up and share information with the Probation Service regarding a patient associating with a high-risk individual. This breakdown in inter-agency communication prevented consideration of further safeguards.
Richard Barraclough
Historic (No Identified Response)
2019-0195 12 Jun 2019
Beatson Clark
Accident at Work and Health and Safety related deaths
Concerns summary Employees are repeatedly exposed to polycyclic aromatic hydrocarbons without protective equipment, despite a clear link to cancer, posing a significant ongoing health risk.
Noah Lomax
All Responded
2019-0186 24 May 2019
Sheffield Children’s NHS Trust
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust should reconsider redesigning the form.
Patrick Kelly
All Responded
2019-0128A 17 Apr 2019
Roseberry Care Centres
Care Home Health related deaths
Concerns summary Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for managing missed appointments or identifying dental care needs.
Aryan Akhgar
All Responded
2019-0115 3 Apr 2019
Sheffield Children’s Hospital Sheffield Clinical Commissioning Group
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A critical gap exists in urgent mental health services for 16 and 17-year-olds in Sheffield, with necessary additional resources for CAMHS lacking guaranteed funding.
Pamela Sunter
Historic (No Identified Response)
2019-0096 20 Mar 2019
Cancer Alliance
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Outdated "two week wait" forms remain on the system, causing confusion due to insufficient priority given to their removal. This hinders efficient clinical administration.
John Duckenfield
All Responded
2018-0389 18 Dec 2018
Brancaster Care
Care Home Health related deaths
Concerns summary Care home staff dishonesty regarding patient observations and GP calls, coupled with inaccurate records, indicated serious failures. Management surprisingly deemed the care reasonable despite these issues.
Ronald Houchin
Historic (No Identified Response)
2018-0376 28 Nov 2018
Rosehill House Care Home
Care Home Health related deaths
Concerns summary Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable falls for the patient.
Elizabeth Self
All Responded
2018-0308 29 Oct 2018
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Senior doctors lacked training in making proper X-ray requests. A communication breakdown caused a valid CT request to remain unattended for hours, leading to significant delays in diagnosis.
Allan Shepard
Historic (No Identified Response)
2018-0313 23 Oct 2018
Sheffield City Council
Community health care and emergency services related deaths
Concerns summary Response times for falls were missed due to inadequate staffing with one-person responder units, and crucial updated patient information was not passed to the third-party call centre.
Mark Nicols
Unknown
17 Sep 2018
Road (Highways Safety) related deaths
Concerns summary Inadequate signage and lighting at a construction site made pedestrian path access unclear, risking public safety, with no indication that future similar situations would be handled differently.
Abigail Hall
All Responded
2018-0286 12 Sep 2018
Derwent Students
Other related deaths Service Personnel related deaths
Concerns summary The continued absence of a defibrillator and first aid trained staff at the premises creates a critical risk for emergency medical response in critical situations.
David Worthington
All Responded
2018-0257 29 Aug 2018
Human Race Limited
Other related deaths
Concerns summary The cycling event's risk assessment inadequately identified a hazardous location with a blind bend, failed to account for high injury potential, and requires a review of its methodology for future events.
Keith Dransfield
All Responded
2018-0273 8 Aug 2018
SHSC
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary An inappropriate observation regime without justification, lack of clear risk assessments, and staff failing to consult patient records, alongside insufficient training, contributed to safety concerns.
Leslie Bingham
All Responded
2018-0228 17 Jul 2018
Sheffield City Council
Road (Highways Safety) related deaths
Concerns summary Pedestrians at a junction may be dangerously misled by a green light for an adjacent crossing, causing them to miss a red light prohibiting them from crossing the main road.
Kay Morrison
Historic (No Identified Response)
2018-0058 26 Feb 2018
Department for Health Royal College of Surgeons
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary There is an insufficient system for collating appropriate antibiotic history, potentially across many hospitals, and a lack of clear requirements for Trusts to adhere to national guidelines on this crucial patient information.
Michael Spencer
Historic (No Identified Response)
2018-0032 5 Feb 2018
Medicines and Healthcare products Regul…
Alcohol, drug and medication related deaths
Concerns summary A specific drug (Andexanet alfa) to reverse potentially fatal bleeding caused by Factor Xa inhibitor anticoagulants is not available in the UK, even for compassionate use.
Dylan Hill
All Responded
2018-0004 4 Jan 2018
Department for Health Food Standards Agency
Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths
Concerns summary A critical lack of communication procedures meant a previous non-fatal anaphylactic reaction at a food business was not reported to Trading Standards, preventing timely regulatory action and risking future deaths.