South Yorkshire (West)
Coroner Area
Reports: 102
Earliest: Aug 2013
Latest: 2 Feb 2026
75% response rate (above 63% average).
Alexandru Murgeanu and Jason Mercer
Partially Responded
2021-0013
19 Jan 2021
Department for Transport
Highways England
Secretary of State for Transport
Other related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Smart motorways present foreseeable risks due to the absence of a hard shoulder and the inability to quickly identify stationary vehicles, necessitating better driver awareness and a wider public inquiry beyond inquest limitations.
Action Taken
(AI summary)
National Highways details numerous actions taken following a stocktake, including installing stopped vehicle detection systems, increasing traffic officers, changing the law to enable automatic detection of Red X violations, and converting dynamic hard shoulder motorways to all lane running. They have launched a road safety campaign and are updating the Highway Code. The Department for Transport commissioned a review of Smart Motorways, is abolishing dynamic hard shoulder motorways, and has launched a £5m campaign to remind road users to ‘Go Left’ in breakdowns. They are upgrading cameras to detect Red X violations and updating the Highway Code with improved safety information.
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 (AI 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.
Noted
(AI summary)
Yorkshire Ambulance Service NHS Trust will audit patients treated at home to gather feedback on information provided, review the PIL template content, conduct spot audits of care plans, launch a communications campaign for staff on detailed care plans for non-conveyance, and develop tick-box indicators on the EPR. The future intention is to embed the PIL content into the EPR and email it to the patient and their primary care provider. The National Medical Director describes existing NHS Pathways triage processes, including the use of a standard set of questions and validation of information by clinicians. They state that shared care records allow clinicians to access information on long-term conditions, medical history, medications, and allergies.
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 (AI 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.
Action Taken
(AI summary)
The Trust updated falls risk assessments to consider mental health, including a direct reference to contacting Mental Health Liaison. They have also informed nursing staff of these changes and shared learning from the case with the Mental Health Strategy Implementation Group.
Emily Greene
All Responded
2020-0288
6 Oct 2020
South Yorkshire Police HQ
Police related deaths
Suicide (from 2015)
Concerns summary (AI 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.
Action Taken
(AI summary)
South Yorkshire Police have taken action in respect of the findings, including ensuring all staff are fully trained on the new incident management system. They are implementing a new 'missing from home' IT system called 'Compact' in April 2021 and refurbishing Achieving Best Evidence rooms.
Eileen Pollard
Historic (No Identified Response)
2020-0053
3 Mar 2020
Crown Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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 (AI 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.
Action Taken
(AI summary)
The Trust has already completed several actions, including providing further training to the staff member involved, reviewing issues with senior staff and external expertise, modifying the patient meal observation chart, and implementing a 'Meal Time Huddle' to ensure staff are aware of patients' dietary requirements.
Sandra Scott
Historic (No Identified Response)
2019-0374
6 Nov 2019
NHS Digital
Royal Hallamshire Hospital
Sheffield Clinical Commissioning Group
+1 more
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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 (AI 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.
Action Taken
(AI summary)
The Trust has refreshed its approach to call-backs, implementing a filter in the CAD system to highlight incidents exceeding expected timeframes, and assigning senior clinical advisors to make call-backs. Reporting mechanisms are being implemented to ensure call-back procedures are followed.
John Gogarty
Historic (No Identified Response)
2019-0200
17 Jun 2019
National Probation Service
RDaSH NHS Trust
Mental Health related deaths
Concerns summary (AI 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 (AI 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 (AI 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.
Action Planned
(AI summary)
The CAMHS team has commenced a review of the referral form, and a draft form was sent to the Clinical Director for Mental Health commissioning at Sheffield Clinical Commissioning Group (SCCG) for comments. The reviewed and updated form and guidance will be distributed to all General Practitioners by 12 July 2019.
Patrick Kelly
All Responded
2019-0128A
17 Apr 2019
Roseberry Care Centres
Care Home Health related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
The care home has implemented a Resident of the Day procedure for care file updates, reviews of care plans, and a diary record for tracking residents' dental care; staff have also attended CCG training on dental hygiene for vulnerable residents.
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 (AI 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.
Action Planned
(AI summary)
Sheffield Children's and Sheffield Health and Social Care Trusts have jointly approved an addendum to the Transitions Policy, implemented a review process overseen by Associate/Directors for young people accessing care, and provided 'read only' access to electronic patient records for CAMHS activity to Sheffield Health and Social Care staff. The CCG approved a business case for a Home Intensive Treatment Team (HITT) on May 7th, 2019, with phased implementation planned from autumn 2019, and has begun recruiting nursing staff.
Pamela Sunter
Historic (No Identified Response)
2019-0096
20 Mar 2019
Cancer Alliance
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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 (AI 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.
Action Taken
(AI summary)
The care home revised its policy on observations and record keeping, trained all registered nurses in January 2019, issued them with the new procedure, and implemented monthly audit checks on care records. Nurse Bogdan completed an observations training module on National Early Warning Score (NEWS2) on 17 January 2019.
Ronald Houchin
Historic (No Identified Response)
2018-0376
28 Nov 2018
Rosehill House Care Home
Care Home Health related deaths
Concerns summary (AI 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 (AI 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.
Action Planned
(AI summary)
NHS England acknowledges the concerns and states they have been working with hospitals to improve standards of care provided to patients under the seven-day services programme, including access to diagnostic imaging. They will disseminate learning from this case through quality structures across England and are undertaking a national review of vaccination and immunisation arrangements.
Allan Shepard
Historic (No Identified Response)
2018-0313
23 Oct 2018
City Wide Alarms
Sheffield City Council
Community health care and emergency services related deaths
Concerns summary (AI 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
All Responded
17 Sep 2018
AMEY
Road (Highways Safety) related deaths
Concerns summary (AI 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.
1 response
from Amey LG Limited
Abigail Hall
All Responded
2018-0286
12 Sep 2018
Derwent Students
Other related deaths
Service Personnel related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
Derwent Facilities Management Limited has commenced a program of emergency first aid training for staff, highlighted the location of the nearest AED within the Premises reception area, and approved the purchase and installation of an AED.
David Worthington
All Responded
2018-0257
29 Aug 2018
Human Race Limited
Other related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Human Race acknowledges the coroner's feedback regarding the tragic accident, but maintains that the events were not reasonably foreseeable. The company states it will take the comments on board when planning and risk assessing future events, but emphasizes the difficulty of anticipating all potential eventualities.
Keith Dransfield
All Responded
2018-0273
8 Aug 2018
SHSC
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
Sheffield Health and Social Care NHS Trust has provided one-to-one supervision to staff involved in the care of Mr. Dransfield, clearly instructed staff about responsibilities in relation to time management and accurate care recording and updated the suicide prevention training to focus on community and inpatient services.
Leslie Bingham
All Responded
2018-0228
17 Jul 2018
Sheffield City Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Pedestrians approaching a road from one direction may be misled by a green light intended for pedestrians crossing from a different direction.
Action Planned
(AI summary)
Sheffield City Council plans to install a length of barrier rail around the corner of the junction within 10 weeks to deter pedestrians from crossing in the wrong location and guide them to the designated crossing point.
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 (AI 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 (AI 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.