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recurance

Marjorie Grayson

16 May 2022 · Coroner Abigail Combes · South Yorkshire (West District)

The coroner's concerns

  1. 1. returning home alone without adequate support

    “Mrs [name redacted] should not return home alone as she was likely to have deteriorated whilst in prison and 4 care and she had expressed suicidal or self-harm related thoughts and (b) she should not be returned to the care of her family because, as unlikely as it may sound, she posed a continued risk to her family.”
  2. 2. inadequate risk assessments and communication

    “Sheffield Health and Social Care Trust did not have risk assessments which supported adequate communication with Mrs [name redacted] herself and instead placed an overburden on her family to advocate for her”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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