“Quality of staff training, particularly with regard to record keeping and communication”
Dated 6 Jan 2014, from the coroner for South Yorkshire East. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 3 Mar 2014. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated6 Jan 2014
- Deadline3 Mar 2014
- Published on judiciary.uk6 Jan 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Rotherham Doncaster and South Humber NHS Foundation TrustNamed in the report as “Rotherham, Doncaster and South Humberside NHS Foundation Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
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The coroner’s concerns
– (1) Quality of staff training, particularly with regard to record keeping and communication. (2) The emphasis on taking a holistic approach to care and whether there is an imbalance between adopting such an approach and patient safety. (3) The absence of clear guidance for checking patients and their rooms for potential self harm items both in the rooms themselves and for items brought into the hospital. (4) The absence of a single reference sheet in the notes summarising key issues, risk factors, significant incidents and concerns readily accessible to all involved in patient care.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2014-0009
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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