Inner North London

Coroner Area
Reports: 331 Earliest: Sep 2013 Latest: 11 Mar 2026

81% response rate (above 63% average).

Response Status
Responded 267 No Response 1 Historic 62
AI Classification
Action Taken 45%
Action Planned 36%
Noted 17%
Disputed 2%
Based on 393 classified responses
Top Categories
Hospital Death (Clinical Procedure… (138) Suicide (from 2015) (47) Other related deaths (43) Alcohol, drug and medication relat… (37) Community health care and emergenc… (31)
Quarterly Trend
Category Breakdown
How does this area compare?
vs London average: +193 reports · +24pp response rate
vs national average: +247 reports · +18pp response rate
Clear 234 results
Tallulah Wilson
All Responded
2014-0047 30 Jan 2014
Department of Health and Social Care
Other related deaths
Concerns summary (AI summary) Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is not standard for psychiatric or medical inductions.
Action Planned (AI summary) The Department of Health highlights a Policy Research Programme investing in projects exploring the internet's role in suicidal behaviour and identifies priorities for prevention. It also mentions that the Royal College of Psychiatrists will recommend making competencies related to media impact compulsory in the next curriculum revision and launching an e-learning tool for children and young people's mental health.
Umul Audu
All Responded
2014-0038 27 Jan 2014
University College London Hospitals NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.
Disputed (AI summary) University College London Hospitals NHS Foundation Trust acknowledges the concerns about the lack of a transport heater, but argues against changing its policy and introducing transport heaters. They believe standard measures are sufficient and their current practice aligns with national standards and that there are contraindications to using such devices for some investigations.
Bertha Cray
All Responded
2014-0037 24 Jan 2014
Barts Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, risking recurrence.
Action Taken (AI summary) The Trust has stopped using double-sided 'nil-by-mouth' signs with different instructions on each side, and will now issue signs with the same instruction on both sides. The family has been informed of the outcome of the investigation and seemed reassured by the changes made by the Trust.
Michael O’Sullivan
All Responded
2014-0012 13 Jan 2014
Department for Work and Pensions
Other related deaths
Concerns summary (AI summary) The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating GP, psychiatrist, and clinical psychologist, leading to decisions without comprehensive medical input.
Action Planned (AI summary) DWP acknowledges concerns and will issue a reminder to staff about guidance related to suicidal ideation. They also state that they will continue to monitor their policies around assessment of people with mental health problems.
Abdullahi Sharif Abokar
All Responded
2013-0323 3 Dec 2013
Camden & Islington NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by inadequate airway management, unactivated oxygen, and staff abandoning the patient.
Action Taken (AI summary) The Trust implemented a "Rapid Improvement Plan" for Coral ward, including mandatory training in suicide risk assessment and in-hospital life support, simulation exercises every 6 months, revised resuscitation scene management, and specialist training in oxygen use. The nurse involved is being managed under the Trust's capability policy.
Barnabas Newlyn
All Responded
2013-0382 13 Nov 2013
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use of air transfer services.
Action Planned (AI summary) NHS England will issue interim guidance on protocols for time-sensitive critical care transfers, offer training to critical care staff in retrieval, mobilise commissioning arrangements for standardising protocols, and commission a report on the feasibility of building the air ambulance service more closely into the critical care neurosurgery pathway.
Timothy Clayton
All Responded
2013-0361-wp26757 11 Nov 2013
Kent Police
Police related deaths
Concerns summary (AI summary) Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading to the loss of six organs.
1 response from Download2013-0558-Response.pdffile
Brian Dorling and Philippine de Gerin-Ricard
All Responded
2013-0265 17 Oct 2013
Transport for London
Road (Highways Safety) related deaths
Concerns summary (AI summary) Confusing unbordered blue strips for cyclists, insufficient education on safer riding techniques, and a dangerous junction contribute to increased road safety risks for both cyclists and motorists.
Action Planned (AI summary) The Mayor of London and TfL are spending almost £1 billion to improve cycling infrastructure, including segregated highways and remodelled junctions, and are committed to upgrading existing superhighway routes.
Michael Sweeney
All Responded
2013-0236 23 Sep 2013
London Ambulance Service Metropolitan Police
Community health care and emergency services related deaths Police related deaths
Concerns summary (AI summary) Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses of underlying medical conditions. Standardising the term to 'extreme agitation' is needed.
Disputed (AI summary) The Metropolitan Police Service has addressed potential information gaps for civil staff with practice notes and in-house training, and developed a detailed joint agency call-handling protocol with the London Ambulance Service. The Medical Director will encourage the adoption of shared terminology and increase awareness in emergency departments. The London Ambulance Service does not agree with the recommendation to use the term 'extreme agitation', preferring 'acute behavioural disturbance' (ABD). They have engaged with police and reviewed guidance, and raised the issue of terminology with the national Ambulance Service Mental Health Working Group, which will issue a position statement after consulting the Royal College of Psychiatrists. They will also share their response with the Pan London Emergency Department Consultants Group.