Inner North London
Coroner Area
Reports: 328
Earliest: Sep 2013
Latest: 3 Mar 2026
79% response rate (above 62% average).
David O’Garro
Historic (No Identified Response)
2014-0270
16 Jun 2014
HMP Pentonville
State Custody related deaths
Concerns summary
A critical failure to complete a cell sharing risk assessment for an epileptic prisoner, coupled with widespread staff unfamiliarity and unclear communication regarding such assessments, created an unsafe cell allocation system.
Stephen Ward
All Responded
2014-0248
29 May 2014
Camden & Islington NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare check, leading to delays when police did not respond.
Gregg O’Reilly
All Responded
2014-0221
19 May 2014
Barts Health
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Missed opportunities to refer to critical care, compounded by a lack of recorded observations over 27 hours, suggest systemic failures in patient monitoring and escalation of care.
Frank Pope
Partially Responded
2014-0216
8 May 2014
Northern Medical Centre
Whittington Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
There is no clear "back-up" process to ensure follow-up for patients lacking capacity, particularly when family members are not copied into correspondence, risking missed appointments.
Peter Brookes
All Responded
2014-0205
7 May 2014
University College London Hospitals NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and an unresolved dispensing error causing wrong medication.
Michael Worrall
Historic (No Identified Response)
2014-0179
22 Apr 2014
Barnet Enfield and Haringey Mental Heal…
Mental Health related deaths
Concerns summary
The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to the community if prior therapy is discontinued.
Francis Golding
All Responded
2014-0136
14 Apr 2014
Camden Council
Road (Highways Safety) related deaths
Concerns summary
The junction design poses significant and repeatedly fatal risks to cyclists due to collisions with left-turning vehicles and inadequate space, with slow progress on promised safety improvements.
Eric Matthews
All Responded
2014-0151
4 Apr 2014
University College London Hospitals NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.
Rosemary Simpson
Historic (No Identified Response)
2014-0142
28 Mar 2014
London Borough of Camden
Road (Highways Safety) related deaths
Concerns summary
The bus stop's location in a busy area creates poor visibility for buses, forcing unsafe lane changes and posing risks to pedestrians and vehicles.
Georgina Swindells
Historic (No Identified Response)
2014-0060
12 Feb 2014
Radiology Reporting Online LLP
University College London Hospitals NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Unexplained image transfer delays, lack of data for investigation, absence of backup systems, and unclear causes for erroneous scan reports indicate systemic failures in radiology services, risking recurrence and misdiagnosis.
Tallulah Wilson
All Responded
2014-0047
30 Jan 2014
Department of Health and Social Care
Other related deaths
Concerns 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 taken summary
The Department of Health has launched an e-learning tool for professionals working with children and young people on mental health. They are also funding research into internet use and suicidal …
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
The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.
Action taken summary
University College London Hospitals NHS Foundation Trust disputes the need to introduce transport heaters, stating their current standard measures for preventing hypothermia are adequate and in line w
Bertha Cray
All Responded
2014-0037
24 Jan 2014
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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 summary
Barts Health NHS Trust has ceased the practice of using double-sided 'nil-by-mouth' signs at bedsides, confirming it was not standard practice. New signs have been issued with the same instruction …
Michael O’Sullivan
All Responded
2014-0012
13 Jan 2014
Department for Work and Pensions
Other related deaths
Concerns 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 taken summary
DWP will issue a reminder to staff about the guidance for requesting further medical evidence in cases where claimants report suicidal ideation. They will also continue to monitor their policies …
Agostino Costa
Unknown
2013-0322
3 Dec 2013
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant safety concerns, exacerbated by inadequate sharing of root cause analysis findings.
Abdullahi Sharif Abokar
All Responded
2013-0323
3 Dec 2013
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Andrew Phrydas
Historic (No Identified Response)
2013-0301
15 Nov 2013
London Underground
Railway related deaths
Concerns summary
London Underground lacked a process for simultaneous dual-line shutdown at intersecting stations and failed to alert the train driver directly and effectively when a person was on the track.
Barnabas Newlyn
All Responded
2013-0382
13 Nov 2013
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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 taken summary
NHS England will issue immediate guidance and establish a training programme for critical care staff on retrieval within a month. They will also commission a report on the feasibility of …
Timothy Clayton
All Responded
2013-0361
11 Nov 2013
Kent Police
Police related deaths
Concerns 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.
Action taken summary
Kent Police disputes the Coroner's report, claiming it contains factual inaccuracies and questions its legitimacy regarding organ viability and the number of lives lost. They state an urgent review of
John William Wright
Historic (No Identified Response)
2013-0285
31 Oct 2013
North Middlesex University Hospital NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors on fall policy and incident recording.
John Lansdowne
Unknown
2013-0360
23 Oct 2013
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Unclear observation records and inconsistent staff understanding of patient observation protocols during bathing, coupled with the use of baths instead of safer walk-in showers, posed risks.
Brian Dorling and Philippine de Gerin-Ricard
All Responded
2013-0265
17 Oct 2013
Road (Highways Safety) related deaths
Concerns 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 taken summary
The Mayor of London plans further research into the use of unbordered blue surfacing on cycle routes to understand user perception and safety. He has also committed to upgrading existing …
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
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.
Action taken summary
The Metropolitan Police Service (MPS) has adopted 'Acute Behavioural Disorder' (ABD) as common terminology, which is now incorporated into police officer training and a new joint agency call-handling
Alan Griffin
All Responded
2021-0243
Other related deaths
Suicide (from 2015)
Concerns summary
Catholic safeguarding failed to adequately scrutinise allegations, delayed providing Father Griffin with details, and offered insufficient pastoral support. Significant delays in the safeguarding investigation were also identified.
Action taken summary
The Catholic Safeguarding Standards Agency has already implemented a new audit and quality assurance function and published a Policy for Safeguarding Case Review Panels, which clarifies requirements f
Lauren Murdock
All Responded
2022-0104
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Concerns summary
A GP miscalculated a patient's clot and cardiovascular risk when prescribing contraception due to misinterpreting guidelines and overlooking critical information, highlighting a need for improved risk assessment.
Action taken summary
The Faculty of Sexual Reproductive Healthcare is commencing a planned update to the UK Medical Eligibility Criteria (MEC) in 2022-2023, intending to improve content formatting for usability. They are