South Yorkshire (West)
Coroner Area
Reports: 102
Earliest: Aug 2013
Latest: 2 Feb 2026
75% response rate (above 63% average).
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 (AI 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.
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 (AI summary)
The decision not to commence CPR was contrary to both Trust and National Policy, potentially impacting patient outcomes.
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 (AI 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.
Roy Middleton
Historic (No Identified Response)
2022-0369
17 Nov 2022
International Academies of Emergency Di…
Emergency services related deaths (2019 onwards)
Concerns summary (AI 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 (AI 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 (AI summary)
The report identifies concerns that a midwife was talked out of seeking support for an episiotomy, leading to delays and inadequate monitoring, and that there was a lack of discussion with the patient about birthing options prior to labour.
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 (AI summary)
Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at risk of harm and death.
Jack Ritchie
Historic (No Identified Response)
2022-0072
7 Mar 2022
Department for Culture, Media and Sport
Department for Education
Department of Health and Social Care
Community health care and emergency services related deaths
Other related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The report identifies that the system of regulation did not prevent the deceased from gambling when addicted, warnings were insufficient, and training for medical professionals on gambling addiction was lacking, particularly for GPs.
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 (AI 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 (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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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