East London

Coroner Area
Reports: 183 Earliest: Sep 2013 Latest: 10 Mar 2026

69% response rate (above 62% average).

Response Status
Responded 126 No Response 4 Historic 46 Pending 5
AI Classification
Action Taken 54%
Action Planned 22%
Noted 19%
Disputed 5%
Based on 63 classified responses
Top Categories
Hospital Death (Clinical Procedure… (98) Mental Health related deaths (25) Community health care and emergenc… (23) Other related deaths (21) Suicide (from 2015) (20)
Quarterly Trend
Category Breakdown
How does this area compare?
vs London average: +47 reports · +11pp response rate
vs national average: +100 reports · +7pp response rate
183 results
Theresa Robertson
Historic (No Identified Response)
2020-0158 6 Aug 2020
Rush Green Medical Centre
Alcohol, drug and medication related deaths Community health care and emergency services related deaths
Concerns summary The surgery failed to document critical patient calls and consultations. A doctor prescribed medication for a high-risk patient outside policy, with no audit to identify similar systemic breaches in prescription safety.
Mitica Marin
All Responded
2020-0066 12 Mar 2020
Department of Health and Social Care London Ambulance Service Physio-Control UK Ltd +2 more
Emergency services related deaths (2019 onwards)
Concerns summary A significant delay in defibrillation occurred because the paramedic was distracted and the device defaulted to manual mode; this is a recurring issue, reducing survival prospects.
Jose Orlando
Historic (No Identified Response)
2020-0063 4 Mar 2020
Tradomi S.L. Transporte
Accident at Work and Health and Safety related deaths
Concerns summary Lorries lacked essential safety features like hand holds for driver access and necessary equipment (CO2 detectors, telescopic mirrors) for Border Force checks, tempting drivers to use unsuitable alternatives.
Lee Carpenter
Historic (No Identified Response)
2020-0052 3 Mar 2020
Goodmayes Hospital Foundation Trust
Community health care and emergency services related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary An urgent GP mental health referral was downgraded without documented rationale, patient/GP discussion, or identification of the decision-making staff, indicating no system for clear documentation and accountability in clinical triage.
Ibiyemi Ereoah
Historic (No Identified Response)
2020-0048 2 Mar 2020
Barts NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Insufficient gynae-oncology consultant cover led to a lack of advocacy in MDT meetings and delayed consultant reviews. There was no system to ensure timely consultant intervention for patients deemed unfit for surgery.
Thiago Araujo
All Responded
2021-0132 29 Jan 2020
Camden and Islington NHS Foundation Tru… Department of Health and Social Care Royal Mail +2 more
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Other related deaths Police related deaths Product related deaths
Concerns summary The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
Doris Clark
Historic (No Identified Response)
2019-0444 19 Dec 2019
Barking, Havering and Redbridge Univers…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), risking opiate overdose. Lack of standardised units between services creates a significant safety concern.
Samantha Higgins
All Responded
2019-0483 13 Dec 2019
North East London Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary A patient remained under a "brief intervention" team for an extended period without an overarching care plan or key-worker, and faced excessive delays (17 months) in accessing crucial psychotherapy treatment.
Karis Braithwaite
Historic (No Identified Response)
2019-0415 20 Sep 2019
Goodmayes Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)
Concerns summary Crucial risk information from first responders was not consistently documented, uploaded, or communicated to the mental health assessment team, highlighting a systemic failure in handover procedures.
John Doyle
Partially Responded
2019-0226 3 Jul 2019
Goodmayes Hospital North East London NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate and outdated training for occupational therapists on emergency Telecare equipment, including ordering processes and compatibility, poses a risk due to rapidly changing technology.
Edir DA Costa
All Responded
2019-0211 27 Jun 2019
Metropolitan Police
Alcohol, drug and medication related deaths Police related deaths
Concerns summary Many police officers are not up-to-date with mandatory Emergency Life Support training, and monitoring compliance is difficult, leading to critical delays in commencing CPR.
Shahida Begum
Partially Responded
2019-0199 18 Jun 2019
Barts Health NHS Trust Royal Docks Medical Practice
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Clinical streamers at Newham University Hospital triage patients based on visual assessment and brief history before vital clinical observations are taken, which is deemed a less safe system.
Frederick Brooker
All Responded
2019-0097 18 Mar 2019
HC-One
Care Home Health related deaths
Concerns summary The care home failed to implement adequate falls prevention, lacking care plans despite identified risks. Multiple falls were not properly investigated or reported, and patient safety was compromised by over-reliance on capacity.
Brenda Gowan
All Responded
2019-0064 25 Feb 2019
Royal London Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate discharge planning for a stroke patient included insufficient social care, disregarded family concerns, unassessed falls risk, lack of community support, and unprovided essential safety equipment.
Sophie Holman
Partially Responded
2019-0035 29 Jan 2019
Department of Health and Social Care NHS England
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Fragmented asthma care lacked coordinated records, long-term management plans, and guideline adherence, resulting in missed risk factors, excessive medication, and no clear clinical responsibility.
Mihaela Lazar
Historic (No Identified Response)
2018-0403 21 Dec 2018
National Fire Chiefs
Community health care and emergency services related deaths
Concerns summary Inadequate fire detection and warning systems, including missing smoke alarms and kitchen doors, combined with unacceptable escape routes in older maisonettes, pose a significant fire risk in thousands of properties.
Dorina Zangari
Historic (No Identified Response)
2018-0403-wp26469 21 Dec 2018
National Fire Chiefs
Community health care and emergency services related deaths
Concerns summary Undermined fire safety measures, absent functioning fire detection, and an inadequate alternative escape route in maisonettes place residents at significant risk of death or injury from fire.
Lauren Sandell
All Responded
2018-0205 25 Jun 2018
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Confusion persists regarding responsibility for vaccinating children not covered by school programs, and the optional nature of GP vaccination services means there's no audit to identify or protect unvaccinated children.
William Bartram
Historic (No Identified Response)
2018-0174 6 Jun 2018
Barts Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Unclear processes for repeat blood samples in babies, failure to highlight abnormal test results, and inadequate discharge advice to parents led to missed critical health issues.
Ahmed Tabeche
All Responded
2018-0143 11 May 2018
Twinglobe Care Homes Limited
Care Home Health related deaths
Concerns summary Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are insufficient, failing to adequately protect at-risk patients.
Maureen Campbell-Scott
All Responded
2018-0090 27 Mar 2018
North East London Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Systemic failures in mental health referral and communication between GP and mental health trust led to significant delays in patient assessment and medication management.
Caliel Smith-Kwami
Unknown
22 Jan 2018
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Critical insulin and amino acid results were delayed due to lab analyser faults and unchased; the electronic record system failed to alert clinicians to new results, hindering diagnosis before discharge.
Bernard Ovu
Historic (No Identified Response)
2017-0425 27 Nov 2017
London Underground
Railway related deaths
Concerns summary Lack of clear written procedures for lone staff dealing with trespassers, inconsistent practice, and difficult access to CCTV for verification contributed to confusion and unconfirmed assumptions.
Kevin Mann
All Responded
2017-0190 15 Jun 2017
Barking, Havering and Redbridge Univers…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A medical procedure was inappropriately performed despite clear radiological contraindications and continued after complications, compounded by the radiologist's failure to check prior imaging and an inadequate, unreviewed procedural policy.
Errol Mann
Historic (No Identified Response)
2017-0128 20 Apr 2017
Barts Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The Intensive Care Unit experienced severe and persistent staffing shortages, including Clinical Fellows, which directly compromised patient care and diverted consultant time from clinical duties.