South Yorkshire (West)

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

75% response rate (above 63% average).

Response Status
Responded 76 Historic 26
AI Classification
Action Taken 48%
Action Planned 31%
Noted 20%
Disputed 1%
Based on 103 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 · +13pp response rate
vs national average: +18 reports · +12pp response rate
Clear 64 results
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.
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 (AI 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.
Action Planned (AI summary) The FSA will be meeting with other government departments and organisations to discuss tackling food allergy issues, and welcomes the Coroner's contribution to these discussions; will also be placing more emphasis on reporting near misses and deaths from food allergy in the Practice Guidance and writing to local authorities to highlight lessons learned and reinforce expectations on good allergen management practices. The Trust has reviewed and updated its anaphylaxis draft protocol and included a referral form to inform Trading Standards of cases of anaphylactic reaction from commercial premises. The draft protocol will be reviewed and ratified at a meeting in March 2018. The FSA will set up a cross-government discussion to consider the reporting of non-fatal anaphylaxis, while Barnsley and Sheffield are exploring the development of local notification systems and considering ways to raise awareness among GPs.
Daisy French
All Responded
2017-0264 9 Nov 2017
Department of Health and Social Care
Child Death (from 2015) Mental Health related deaths
Concerns summary (AI summary) The report identifies concerns regarding communication and information sharing between CAMHS and Adult Services, the transition of care, and out-of-hours provision for 16 to 18 year olds, and the appropriateness of placing under 18s in adult crisis houses or supported living without staff.
Noted (AI summary) Sheffield Health and Social Care NHS Foundation Trust and Sheffield Children's NHS Foundation Trust are working jointly, updating team protocols to ensure young people returning home to independent or supported living receive contact within 24 hours of A&E discharge. They have also identified an Operational Director Lead and will participate in a city-wide review, expecting a report between March and May 2018. The Department of Health acknowledges the concerns and explains the national position on transitioning between children's and adult mental health services, referencing NICE guidelines and NHS England's financial incentives. They note that local NHS organisations are responsible for reviewing local health services and mention actions taken by the NHS in Sheffield, including training, a Section 136 suite, and a Mental Health Liaison Consultant. They also note a safeguarding review to be completed by April 2018.
John Higgs
All Responded
2017-0113 10 Apr 2017
Department of Health and Social Care
Other related deaths
Concerns summary (AI summary) The system for communicating unexpected, non-cancerous radiological findings is flawed, relying solely on one doctor to notice and input information, with no "red flag" or specific protocol for critical non-cancerous results.
Action Taken (AI summary) The Trust will reissue existing Guidance on Communication of Critical or Urgent Radiological Findings to relevant clinical staff who joined after 2016 and disseminate it via a Patient Safety Bulletin. They are also working towards the RCR's Standards for communication of radiological reports.
Terence Millington
All Responded
2017-0035 2 Mar 2017
Sheffield Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate arrangements for on-call doctors, including a senior doctor's failure to ensure availability and a consultant's distant location, delayed prompt emergency care and a blood product request was incorrectly met.
Action Taken (AI summary) Sheffield Teaching Hospital NHS Trust has discussed the incident with the doctor concerned and included reference to on-call responsibilities in the local induction program. An emergency epistaxis bag is now available and monitored on ward I1, and the incident will be presented at the Trust's Safety and Risk Management Board meeting.
Sheila Bowling
All Responded
2017-0010 7 Feb 2017
First Mainline
Road (Highways Safety) related deaths
Concerns summary (AI summary) A 'Drive Clean System' in the vehicle, which encourages smooth driving, may have discouraged the driver from making necessary evasive steering movements, potentially contributing to the fatality. The system's influence on driver response requires review.
Disputed (AI summary) First Bus refutes that the 'Drive Green' system has any adverse impact on safety, stating that collisions in South Yorkshire have reduced by 23.5% since its introduction in 2010. They describe driver training, a Driving Standards Manager, and a safe driving bonus scheme, but maintain that safety is the number one priority.
Carol Leesley
All Responded
2016-0442 12 Dec 2016
Sheffield City Council
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown systemic or IT error, leaving a patient vulnerable.
Action Taken (AI summary) Sheffield City Council has amended the automated response to safeguarding reports to include a notification that, if the person making the report is not contacted within 2 working days, they should contact the Adult Access team to check that the report has been received. They have implemented an email Journal facility which will provide an on-going audit log of all emails received and sent for the relevant mailbox used by Adult Access. They have requested a forensic report and audit log to trace the email and have logged this as a Serious Incident.
Jonathan Sellman
All Responded
2016-0395 17 Aug 2016
Rotherham Borough Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) Water pooling on a busy road and verges that could propel cars over safety barriers create hazardous driving conditions, despite the drainage being considered operative.
Noted (AI summary) Rotherham MBC provides detailed information about its road maintenance and inspection regimes, but does not commit to any changes as a result of the coroner's concerns.
Marjorie Nesbitt
All Responded
2016-0263 25 Jul 2016
Sheffield City Council
Community health care and emergency services related deaths
Concerns summary (AI summary) Carers lacked training and clear guidance on how to manage unusual and difficult situations, specifically regarding an overheating client from a heater, leading to a fatal outcome.
Action Planned (AI summary) The council has prepared documents including a case study overview and practical advice for support workers, which it intends to share as a training tool with internal and commissioning services, Sheffield Teaching Hospitals, social workers, care managers, and council quality and safeguarding teams.
Neil Budziszewski
All Responded
2015-0109 23 Mar 2015
South Yorkshire Police
Police related deaths
Concerns summary (AI summary) Multiple failures in police custody included incomplete and unreviewed risk assessments, lack of 30-minute rousing checks for an alcoholic detainee, and inadequate staff training on managing risks associated with alcohol withdrawal.
Action Planned (AI summary) South Yorkshire Police will highlight the importance of opening a custody record and completing a risk assessment, even when a detainee is uncooperative, in training and through a briefing document and rotational training. They will also incorporate information about acute alcohol withdrawal syndrome into first aid training for custody staff.
Ahmad Khan
All Responded
2014-0291 28 Jun 2014
Q-Park Limited Sheffield City Council (Planning) Sheffield County Council
Other related deaths
Concerns summary (AI summary) Easy access to a low perimeter wall, facilitated by a nearby barrier, creates a dangerous fall hazard for individuals, including children.
Noted (AI summary) Sheffield City Council found no breach of planning control or building regulations at the car park. However, they have suggested alterations to Q Park Ltd to prevent similar incidents and are open to working with the company on a solution.
Lucy Moffatt
All Responded
2014-0261 10 Jun 2014
Care Quality Commission Department of Health and Social Care
Mental Health related deaths
Concerns summary (AI summary) Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded by CQC inspectors' unawareness of a critical Department of Health alert.
Action Planned (AI summary) The CQC is reviewing its registration process to include specific questions on safety alerts, and piloting pre-inspection methodology to assess dissemination of safety alerts by providers. The Department of Health discussed the report with the CQC, who will take steps to improve the implementation of Safety Alerts, including Department of Health Alerts.
Jude Augustus Gordon
All Responded
2013-0237 24 Sep 2013
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for a deteriorating patient.
Noted (AI summary) The Department of Health acknowledges the concerns, noting existing work on a national early warning score (NEWS) and the use of computerised systems in some Trusts. However, it states that there are no current plans to mandate computerised EWS systems nationally due to IT infrastructure limitations, and emphasizes the importance of local training.