Inner North London
Coroner Area
Reports: 331
Earliest: Sep 2013
Latest: 11 Mar 2026
81% response rate (above 63% average).
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
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 (AI 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
Historic (No Identified Response)
2013-0360-wp26756
23 Oct 2013
Camden & Islington NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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
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.