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
Clear 25 results
Shaun Parks
Historic (No Identified Response)
2023-0538 20 Dec 2023
Department of Health and Social Care West Yorkshire Integrated Care System
Emergency services related deaths (2019 onwards)
Concerns summary An excessive ambulance response time was caused by insufficient emergency medical dispatchers and significant hospital patient offloading delays, tying up resources and impacting emergency call response.
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 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.
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 The decision not to commence CPR was contrary to both Trust and National Policy, potentially impacting patient outcomes.
Roy Middleton
Historic (No Identified Response)
2022-0369 17 Nov 2022
International Academies of Emergency Di…
Emergency services related deaths (2019 onwards)
Concerns summary The emergency dispatch algorithm fails to account for anticoagulant medication in head injury cases, risking delayed appropriate responses and future deaths.
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 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.
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 Concerns include a midwife being dissuaded from a necessary procedure, leading to delivery delays, inadequate fetal monitoring, and a lack of pre-labour birthing option discussions. "Normal birth" language on checklists is also concerning.
Jack Ritchie
Historic (No Identified Response)
2022-0072 7 Mar 2022
Department of Health and Social Care Department for Education Department for Culture, Media and Sport
Community health care and emergency services related deaths Other related deaths Suicide (from 2015)
Concerns summary Systemic failures in gambling regulation, inadequate warnings and information, insufficient treatment for addiction, and a lack of training for medical professionals contributed to a preventable death.
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 Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at risk of harm and death.
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 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.
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.
Sandra Scott
Historic (No Identified Response)
2019-0374 6 Nov 2019
Upwell Street Surgery Royal Hallamshire Hospital 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.
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.
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.
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.
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.
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.
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 Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical error during patient transfer.
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 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.
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 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 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 Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police when she disappeared, were significant concerns.
John Michael Bailey
Historic (No Identified Response)
2013-0198 9 Sep 2013
Department of Health and Social Care
Community health care and emergency services related deaths
May Gibson
Historic (No Identified Response)
2013-0199 30 Aug 2013
Herries Lodge Care Home
Community health care and emergency services related deaths
Concerns summary The care home exhibited widespread systemic failures, including inadequate assessments, poor care planning, insufficient risk management, and a lack of cohesive management and staff training.