East London

Coroner Area

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

69% response rate (above 62% average).

vs London average: +47 reports · +11pp response rate

vs national average: +100 reports · +7pp response rate

Douglas Grey

Historic (No Identified Response)

2013-0253 3 Oct 2013

Floron Residential Home

Care Home Health related deaths

Concerns summary Lack of clear written procedures for equipment delivery, installation, and review. Carers also failed to recognise and report faulty equipment despite a written policy, compromising resident safety.

Tripta Rani Kumar

Historic (No Identified Response)

2013-0235 19 Sep 2013

Queen’s Hospital

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A patient with a documented penicillin allergy was prescribed penicillin-containing medication after a critical allergy note was incorrectly overwritten without authorisation, creating a serious risk of anaphylaxis.

James Taylor

Continuing Care Redbridge Clinical Commissioning Group …

Community health care and emergency services related deaths Mental Health related deaths Suicide (from 2015)

Concerns summary Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise continuity of care.

Action taken summary Barking Dagenham Havering and Redbridge CCG, in collaboration with NELFT, has implemented changes to psychological therapies service procedures, increased service capacity, and updated panel protocols

Paul Sartori

Barts Health NHS Trust and North East L… Royal College of Emergency Medicine

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Systemic misdiagnosis of thoracic aortic dissection is prevalent due to a lack of awareness, education among clinicians, and potentially inadequate diagnostic tools in emergency departments.

Action taken summary Barts Health has updated streaming policy at Whipps Cross to include THINK AORTA guidance, delivered related training, and updated its Heart Attack Centre feedback template. They will ensure pre-arriv

Ian Cockfield

Department of Health and Social Care an…

Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths

Concerns summary The concerns text refers to a narrative conclusion not provided, therefore no specific issues can be summarised from the given text.

Action taken summary The Department of Health and Social Care notes existing NICE guidelines for falls risk assessment and that NICE is updating this guidance, due 2024, to include patients under 65 with …

Louise Allen

North East London NHS Foundation Trust …

Mental Health related deaths Railway related deaths Suicide (from 2015)

Concerns summary An inadequate care plan resulted from severe failings in care coordination, stemming from insufficient, underpaid, and overworked care co-ordinators facing high caseloads and staff turnover.

Action taken summary The Trust conducted a pay review in July 2021, upgrading all Band 5 Nurses to Band 6, and gave a £1000 payment to Band 6 Care Coordinators in October 2021. …

Michael Vince

North East London Foundation Trust and …

Alcohol, drug and medication related deaths Mental Health related deaths

Concerns summary A patient was prescribed a short-term medication for 20 years against guidelines without meaningful review or monitoring of PRN use, and dependence evidence was not shared between health trusts.

Action taken summary High Street Surgery conducted an audit of all patients prescribed Zopiclone, contacted all current patients for a structured medication review, and updated its Z-Drug Protocol. The surgery has also co

Daniel Xavier

Barts Health NHS Trust Department of Health and Social Care

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Hospital staff failed to act on dangerously elevated blood test results and provided chaotic handovers to surgical teams. Insufficient consideration was given to the patient's learning disability.

Action taken summary The Department of Health and Social Care has introduced a new legal requirement for CQC registered service providers to ensure employees receive learning disability and autism training, effective July