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
102 results
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.
Sean Salvin
Partially Responded
2017-0103 4 Apr 2017
Amey PLC Sheffield Council South Yorkshire Police +1 more
Road (Highways Safety) related deaths
Concerns summary (AI summary) Inadequate information sharing, inaccurate incident location, and deficient risk assessments for highway hazards (including flooding and tree growth impacting lighting) contributed to ongoing road safety concerns.
Action Taken (AI summary) The council, along with other agencies, has developed a new Highway Flooding Priority Rating System, operational by June 30th, 2017. They've also improved existing procedures and protocols for information sharing between agencies.
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.
Simon Harper
Historic (No Identified Response)
2016-0410 9 Nov 2016
Department for Health
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical error during patient transfer.
Captain James Bedforth
Partially Responded
2016-0368 18 Oct 2016
Barnsley Hospital NHS Trust Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate DVT scanning guidelines and poor safety-netting led to missed diagnosis. Delayed assessment in ED, issues with anticoagulation management, and poor note-keeping further compromised care.
Noted (AI summary) The Department of Health acknowledges the coroner's concerns regarding lower leg scanning for DVT, but refers the matter to NICE and the Royal Society of Medicine Venous Forum for further comment.
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.
Adam Miles
Partially Responded
2016-0132 29 Mar 2016
British Waterways Canal and River Trust Hilton Hotel
Other related deaths
Concerns summary (AI summary) The hotel allowed smoking near the canal without adequate barriers to prevent falls, and the canal itself lacked any means of escape for individuals who fell in.
Action Planned (AI summary) The hotel has posted signage about the lack of smoking area on the canal side and risks of deep water. They also plan to install a new CCTV unit on the canal side. The Canal & River Trust proposes placing two additional life rings on the side of the basin closest to the hotel and placing additional "Danger deep water" signs at locations around the basin.
John Robinson
Historic (No Identified Response)
1 Sep 2015
Clinical Commissioning Group
Community health care and emergency services related deaths
Concerns summary (AI summary) The unavailability of a psychiatric bed for Mr Robinson led to his deteriorating condition and death, raising concerns about insufficient mental health resources in the area.
Paul Littlewood
Partially Responded
2015-0187 13 May 2015
Steadplan Ltd Freight Transport Association Ltd Road Haulage Association
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) Gantry safety barriers were too low, lacked an intermediate crossbar and toe-plate, and fall protection at the access ladder was inadequate, creating significant fall risks.
Noted (AI summary) The Freight Transport Association extends condolences and states that it will continue to provide guidance to members in relation to assessing and managing their risk, including their guide 'Preventing Falls from Vehicles'.
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.
Alexander Holt
Historic (No Identified Response)
2015-0040 3 Feb 2015
Sheffield Health and Social Care Trust
Community health care and emergency services related deaths
Concerns summary (AI summary) Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, leading to inadequate risk assessment and a broken referral process.
Anthony Offord
Partially Responded
2014-0396 8 Sep 2014
Department of Health and Social Care Yorkshire Ambulance Service
Community health care and emergency services related deaths
Concerns summary (AI summary) Emergency medical dispatch staff lacked training on respiratory distress signs. Protocols were absent for ambulance crew "stand-offs," considering alternative support, or managing ambulance availability during meal breaks.
Action Taken (AI summary) Yorkshire Ambulance Service reviewed training for EMD staff, clarified management involvement in 'stand off' decisions, and reinforced consideration of alternative support methods. They are also reviewing the meal break policy to balance staff needs and patient safety, and have reminded staff about incident reporting procedures.
Peter Stanley
Partially Responded
2014-0390 2 Sep 2014
Department for Education GEOAmey South Yorkshire Police +1 more
Alcohol, drug and medication related deaths
Concerns summary (AI summary) A lack of formal 'step-down' policy exists for young people discharged from or failing to engage with Adult Mental Health Services. Additionally, there is insufficient encouragement for insurers to deny cover to establishments selling 'legal highs' linked to mental health issues.
Action Taken (AI summary) PECS has reviewed its contractors' operational policies to ensure staff understand and adhere to the requirement to share Prisoner Escort Records (PER) with relevant parties, including Youth Offending Services, and has reminded Geo Amey of this requirement. This will be reinforced in staff briefings and safer custody training.
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.
Denise Parramore
Historic (No Identified Response)
2014-0247 19 May 2014
NHS England NHS Sheffield Clinical Commissioning Gr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A lack of open, two-way communication and inability to access shared documentation between primary and secondary care meant psychiatric services were unaware of critical medication prescriptions.
Gavin Roberts
Historic (No Identified Response)
2014-0120 14 Mar 2014
Rotherham Metropolitan Borough Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) The current 60mph speed limit for a specific bend is too high, and warning signs are inadequate, particularly as the limit increases on approach, contributing to repeated incidents.
Pamela Bailey
Historic (No Identified Response)
2014-0040 27 Jan 2014
Sheffield Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police when she disappeared, were significant concerns.
William Andrews
Partially Responded
2013-0368 17 Dec 2013
Care Quality Commission Department of Health and Social Care Secretary of State for Health
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led to a retained tip. A national safety recommendation for such caps was ignored, and no cap counting procedure exists.
Action Taken (AI summary) The manufacturer of syringes has agreed to supply syringes without caps, has issued a safety notice to all UK customers, and will make syringes without caps available for stock exchange. The Director of Patient Safety at NHS England has written about the taskforce to look at surgical never events and highlighted Royal College of Surgeons (RCS) revision of their practice guidance.
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.