“During evidence from the family and , author of the internal investigation, it became…”
Dated 26 Mar 2024, from the coroner for South Yorkshire West. Sent to 2 organisations or people.
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 21 May 2024. 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 dated26 Mar 2024
- Deadline21 May 2024
- Published on judiciary.uk15 Apr 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sheffield Teaching Hospitals NHS Foundation TrustNamed in the report as “Sheffield Teaching Hospital Trust NHS Foundation Trust” | Response publishedPublished on judiciary.uk in April 2024. |
| Sheffield Children's NHS Foundation TrustNamed in the report as “Sheffield Children’s NHS Foundation Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 21 May 2024. A reply may have been sent and not yet published. |
The coroner’s concerns
During evidence from the family and , author of the internal investigation, it became clear that although Craig had received care for the shunts implanted as a consequence of his hydrocephalus as a young person, this did not continue as an adult. Also, there was no process for review of patients such as Craig. gave evidence that there remained no transfer protocol or pathway in place as children move into adulthood as at the current date nor an effective review process for adults at the present time. In evidence she stated that it was important that a clear pathway, including for transitions between childhood and adulthood, was in place and a failure to have such clear pathways and protocols such that people who needed care could easily access it could potentially be fatal.
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, 2024-0181
- 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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