East London
Coroner Area
Reports: 183
Earliest: Sep 2013
Latest: 10 Mar 2026
70% response rate (above 63% average).
Paul Kalnins
All Responded
2015-0278
15 Jul 2015
Metropolitan Police
Other related deaths
Concerns summary (AI summary)
Communications officers lacked current training and struggled with a complex database where critical risk information was not easily accessible or prominently displayed, jeopardising vulnerable persons.
Action Planned
(AI summary)
The Metropolitan Police Service will implement mandatory refresher training for communications officers on the Merlin database by March 31st 2016, focusing on the 'red flag' marker and incident reports. Line managers have been instructed to monitor training completion.
Joseph Allison
All Responded
2015-0103
23 Mar 2015
British Healthcare Trades Association
Handicare Accessibility Ltd
Product related deaths
Concerns summary (AI summary)
Service engineers lack specific training on a known stairlift defect and safety checks. Furthermore, no national safety recall or industry-wide advisory has been issued for the defective Minivator 2000 stairlift.
Action Planned
(AI summary)
Handicare has adjusted internal processes and training for in-house engineers. It will also raise the issue of sharing safety information with all manufacturers at the next BHTA stairlift section meeting and via letter during the week commencing 15th June 2015. BHTA will remind manufacturer members to continue training to address field safety issues until all products have been traced and necessary action taken. BHTA will recommend that the Health & Safety Executive talk to the MHRA and see if they might tap into the alerting system for alerts regarding products sold into the care sector.
Michael Lyons
All Responded
2015-0067
20 Feb 2015
John Stanley Agency
Care Home Health related deaths
Concerns summary (AI summary)
The care agency failed to act on swallowing assessment recommendations, resulting in an inadequate care plan that did not specify choking prevention measures, and staff lacked crucial awareness regarding food preparation.
Disputed
(AI summary)
The care agency disputes responsibility, stating that they were not informed of Mr. Lyons' swallowing difficulties or risk of choking by social services or family, and therefore could not supervise him adequately during mealtimes.
Awa Jeng
All Responded
2015-0015
20 Jan 2015
Barts Health
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by a consultant were not performed, indicating failures in monitoring, task handover, and medical review.
Action Taken
(AI summary)
The trust is implementing a revised early warning score system (NEWS and CREWS), has been awarded funding to implement a vital signs monitoring process (Vitalslink), has a full complement of middle grade doctors, holds regular mortality and morbidity meetings, sent instructions to junior doctors regarding trauma sheet completion, and discusses all renal dialysis patients with the renal team.
Peter Jeffrey
All Responded
2013-0313
27 Nov 2013
Guys & St Thomas'NHS Foundation Trust (…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and overlooked intravenous antibiotics after negative DVT scans.
Noted
(AI summary)
The Trust reviewed records but states it is unable to respond fully to the concerns due to a lack of clarity regarding the patient's condition in the months before his death. They offer to remind medical teams about antibiotic administration options.