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
331 results
Thomas Taylor
Historic (No Identified Response)
2014-0388 1 Sep 2014
Royal Free London NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The ward lacked clear leadership and support, there was no protocol for lost notes and drug charts, and there seemed to be no well-understood protocol when the patient refused a blood sugar check.
Irshad Ali
All Responded
2014-0387 29 Aug 2014
Barts Health
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The report identifies missing records of required nursing observations, a failure to complete neurological observations before discharge as stipulated, and miscommunication regarding physiotherapy assessment before discharge.
Action Taken (AI summary) The Trust has taken multiple actions including monthly nursing audits of patient note filing, reminders to nurses about discharge policies, and a review of processes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team, and the Senior Sister will be given a copy of the consultants' rota to facilitate nursing presence on ward rounds.
Noleen McPharlane
All Responded
2014-0370 7 Aug 2014
Camden and Islington NHS Foundation Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate mental health care included a failure to directly assess suicidal ideation or illicit drug use, short sessions, and a lack of input from other professionals despite poor patient rapport.
Action Planned (AI summary) The Trust updated its clinical risk assessment and management policy in September 2014. All clinical staff will be instructed to discuss methods of self-harm with service users and care plans will be set to prevent self-harming practices by November 2014.
Toni Skillington
Historic (No Identified Response)
2014-0369 31 Jul 2014
London Ambulance Service NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The dispatch system inadequately captured methadone overdoses and patient solitude. Welfare checks were not actioned, resulting in a three-hour delay in paramedic response to an overdose.
Monique Whitbread
Historic (No Identified Response)
2014-0368 30 Jul 2014
University College Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A gastric bypass procedure inadvertently led to hernia strangulation and death in a bariatric patient. The surgeon's revised practice of using sleeve gastrectomy for patients with hernias should be nationally disseminated.
Shayla Walmsley
Historic (No Identified Response)
2014-0323 14 Jul 2014
Department of Health and Social Care Medicines and Healthcare Products Regul… Medtronic +1 more
Other related deaths
Concerns summary (AI summary) Delays in obtaining medical device data from manufacturers, inconsistent distribution of safety notices, and a lack of post-mortem analysis of medical devices hinder investigations and timely safety interventions.
Harold de Mello
All Responded
2014-0449 7 Jul 2014
Tower Hamlets Social Services
Community health care and emergency services related deaths
Concerns summary (AI summary) A lack of good practice guidelines led to incomplete and inaccurate assessments by First Response Officers, who failed to reconcile conflicting information, investigate actual care needs, or consult relevant family.
Action Planned (AI summary) Tower Hamlets Social Services has convened a Case Review meeting and commissioned an internal management review. They are developing a risk analysis tool, introducing an eco-mapping tool, and scheduling targeted training, with further changes planned due to the implementation of the Care Act 2015.
Ralph Goslin
All Responded
2014-0282 25 Jun 2014
University College London Hospitals NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, delaying the recognition of missed medication.
Action Taken (AI summary) The trust has commissioned specialist epilepsy training from the National Neurological Commissioning Support Unit, working with the National Epilepsy Society, across inpatient and residential services. The process for sharing recommendations has been changed to ensure follow-up and written communication with all members of the group.
David O’Garro
Historic (No Identified Response)
2014-0270 16 Jun 2014
HMP Pentonville
State Custody related deaths
Concerns summary (AI summary) The report cites that a nurse did not complete a cell sharing risk assessment and staff lacked clarity and shared understanding regarding the assessment process for prisoners with epilepsy.
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 (AI 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.
Noted (AI summary) Response is blank.
Gregg O’Reilly
All Responded
2014-0221 19 May 2014
Barts Health
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The coroner noted a missed opportunity to refer the deceased to critical care, and the lack of observation records during a critical period before the deceased suffered a second bleed and cardiac arrest.
Action Planned (AI summary) Barts Health NHS Trust has concluded an investigation and outlined recommendations including recruiting a Band 7 Sister, shortening the transition to an electronic patient record, establishing a Critical Care Board (meeting August 2014), and launching an education strategy to identify deteriorating patients.
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 (AI 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.
Action Planned (AI summary) The Trust will send a communication to all GPs via the GP Bulletin to remind them to include any information with regard to vulnerable patients or patients who lack capacity in the referral letter. They will also remind them of the option to request that out-patient appointment letters be copied to either a nominated patient representative for patients who lack capacity to attend 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 (AI 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.
Action Taken (AI summary) The Trust has a policy that all new patients should have their medication reconciliation completed within 24 hours and are looking to achieve 100% compliance. It also has measures in place to minimise the risk of dispensing errors including double checks, separate storage of similar drugs and mandatory reporting of errors.
Michael Worrall
Historic (No Identified Response)
2014-0179 22 Apr 2014
Barnet Enfield and Haringey Mental Heal…
Mental Health related deaths
Concerns summary (AI 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 (AI 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.
Action Planned (AI summary) Camden Council will issue a brief to traffic consultants by the end of May 2014 to invite tenders for traffic signal modelling in the Holborn area, including the Southampton Row/Vernon Place junction, with consultants expected to be appointed in mid-June 2014.
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 (AI summary) There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.
Noted (AI summary) The Trust investigated a survey of 'cot deaths' in unusual scenarios but it did not prove feasible due to data protection and consent issues. They suggest coroners liaise with clinicians working on sudden infant death and release data from existing child death reviews.
Rosemary Simpson
Historic (No Identified Response)
2014-0142 28 Mar 2014
London Borough of Camden
Road (Highways Safety) related deaths
Concerns summary (AI 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 (AI summary) The coroner identified concerns regarding delays in image transfer, a lack of available data to investigate the issue, the absence of an image transfer backup process, and the apparently erroneous scan report, raising the possibility of misreporting in the future.
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.
Agostino Costa
Historic (No Identified Response)
2013-0322 3 Dec 2013
The Whittington Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Andrew Phrydas
Historic (No Identified Response)
2013-0301 15 Nov 2013
London Underground
Railway related deaths
Concerns summary (AI 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.