Inner North London

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

81% response rate (above 63% average).

Clear 234 results
Miranda Avanzi
All Responded
2024-0626 14 Nov 2024
Department for Culture, Media and Sport OFCOM
Suicide (from 2015)
Concerns summary (AI summary) The widespread and easily accessible availability of explicit, step-by-step suicide guides online, often without age verification, poses a significant risk, enabling vulnerable individuals to self-harm.
Action Planned (AI summary) DSIT is working with Ofcom to implement the Online Safety Act 2023, which tackles illegal and legal forms of online suicide content. The Act requires services to assess the risk of users encountering illegal content and to remove legal content prohibited in their terms of service. Ofcom is providing guidance to services on identifying content that illegally encourages or assists suicide, and search providers have duties to remove or lower the ranking of illegal suicide content. Ofcom is working with services to promote compliance and will take enforcement action if needed, taking evidence from coroner's reports into account.
Sarah McGreevy
All Responded
2024-0611 6 Nov 2024
London Borough of Hackney
Other related deaths
Concerns summary (AI summary) Residents unsafely climb onto balconies to clear blocked drainpipes, posing a fall risk. The absence of remedial works means this dangerous practice is likely to continue.
Action Planned (AI summary) The Borough will publish a message in the January edition of 'Love Hackney' reminding residents not to use steps/ladders on balconies and to contact the repairs centre for guttering/pipework issues. They also conducted a survey of the external elements and elevations, focusing on surface water drainage serving the balconies, and found no defects except for temporary tape applied to one balcony.
Jagjeet Singh
All Responded
2024-0606 4 Nov 2024
Department of Health and Social Care NHS England
Alcohol, drug and medication related deaths
Concerns summary (AI summary) A chronic national shortage of mental health beds meant a patient was repeatedly without a bed upon medical discharge, forcing him into unsuitable accommodation or rough sleeping.
Noted (AI summary) NHS England is investing in new units and system transformation to increase access to mental health beds, and London regional colleagues are engaging with the North East London Integrated Care Board on system arrangements for mental health inpatient beds. The Department acknowledges concerns about bed availability and highlights existing initiatives to improve community mental health support and patient flow, referencing published guidance on discharge from mental health inpatient settings.
Wayne Bayley
All Responded
2024-0605 31 Oct 2024
Ministry of Justice NHS England
State Custody related deaths
Concerns summary (AI summary) National replication of healthcare improvements, especially understanding sickle cell crisis risks and prisoner care, has not occurred across all UK prisons, posing a risk that lessons learned are not widely applied.
Noted (AI summary) NHS England is undertaking training and upskilling of healthcare and prison staff in the London region. They are also reviewing service specifications and will use learning from the case to strengthen requirements around assessment and management of long-term conditions. HMPPS acknowledges the concerns and refers to ongoing work led by NHS England to improve awareness of sickle cell disease and other long-term conditions, stating their commitment to working collaboratively with healthcare providers.
Ian Hegarty
All Responded
2024-0583 28 Oct 2024
Barts Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A care plan designed to reduce falls risk for multiple patients was not followed, and the ongoing internal investigation provides insufficient reassurance that this critical risk has been addressed.
Action Planned (AI summary) Barts Health NHS Trust is undertaking a Patient Safety Incident Investigation (PSII) to identify opportunities for learning and improvement following a patient fall, and will use the findings to identify actions to improve patient safety, recording actions on Datix.
Kashim Ali
All Responded
2024-0582 28 Oct 2024
East London NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant risks for future patients.
Action Taken (AI summary) East London NHS Foundation Trust has mandated a two-day physical health training course for inpatient nursing staff, updated its physical health observation policy, and introduced an updated Observations and Therapeutic Engagement Policy, including Honesty in Documentation training.
George Kyriacos Petrou
All Responded
2024-0592 25 Oct 2024
Barnet, Enfield and Haringey Mental Hea…
Mental Health related deaths State Custody related deaths
Concerns summary (AI summary) Some prison mental health staff improperly prioritized a prisoner's refusal of suicide watch over policy guidance, creating a risk that vulnerable individuals with suicidal intentions may not receive necessary observation.
Action Planned (AI summary) The Trust will continue to assure training standards around ACCT are sustained, will continue to participate in ACCT reviews in accordance with its operational policy, and will implement a learning event for the Unscheduled Care Team workers and clinicians. The learning event will focus on the message, ‘if in doubt, implement an ACCT’.
Michael Crane
All Responded
2024-0581 25 Oct 2024
Metropolitan Police Prime Life Limited
Mental Health related deaths Police related deaths
Concerns summary (AI summary) Police officers lacked guidance on using Mental Health Act powers and managing individuals likely missing but not officially reported, hindering their ability to ensure safety in critical situations.
Action Taken (AI summary) The MPS runs a scenario based approach to Public and Personal Safety Training (PPST), focusing on different interactions an officer is likely to face in the course of their day to day duties. This training is mandatory for all operational police officers and Detectives within the MPS. Prime Life has reviewed its missing person policy and has provided additional training to the staff and management at Island Place in order to ensure that they have clear guidance on when and understanding in how quickly a person should be reported missing. There are a full set of policies and procedures available to all staff, which have since undergone a full review.
Chamali Bibi
All Responded
2024-0540 9 Oct 2024
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns exist regarding the expertise and frequency of PAO surgeries, as many surgeons perform very few procedures annually without adequate oversight or recognition of the procedure's specialized nature.
Noted (AI summary) NHS England acknowledges the concerns about periacetabular osteotomy (PAO) procedures and states that it is a specialist procedure that should be undertaken only by clinicians with the requisite training and experience. They defer further comment on the specific concerns to Barts Health NHS Trust and suggest the coroner refer to the Royal College of Surgeons or the British Orthopaedic Association for further information.
Sophie Dean
All Responded
2024-0517 30 Sep 2024
University College London Hospitals NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Incomplete medical record documentation by junior doctors and a surgeon's failure to fully inform parents about treatment options hindered truly informed consent for surgery.
Action Taken (AI summary) UCLH will implement a standard ward round note with minimum information requirements, will audit notes within 12 months, has amended the consent policy to require a second consultant opinion for high-risk emergency surgeries where the patient lacks capacity, and will incorporate PFD learning into Trust induction within three months.
Laura Farmer
All Responded
2024-0496 16 Sep 2024
UK Health Security Agency University College London Hospitals NHS…
Other related deaths
Concerns summary (AI summary) Public health authorities failed to adequately investigate a fatal E. coli source, neglecting to gather crucial family information or provide infection control advice. There was no feedback loop to clinicians, leaving the family without answers or safety guidance.
Action Planned (AI summary) UKHSA will undertake a risk assessment in collaboration with the clinical team treating a case to determine whether additional contact should be made with the next of kin when a case is known to die during investigation; contact details of the UKHSA regional team will be shared with immediate family so they can contact the regional team if they have any questions or would like to provide any further information. UCLH will reinforce how they make relevant infection information available to patients and their next of kin and will reflect on this case. They will also endeavour to document health protection team contact details in their electronic health records system.
Daniel Klosi
All Responded
2024-0462 16 Aug 2024
Royal College of Emergency Medicine Royal College of Paediatrics and Child … Royal Free Hospital
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A distressed neurodiverse child did not receive full observations for over four hours in a busy emergency department, leading to a catastrophic cardiovascular compromise and highlighting challenges in assessing such patients.
Noted (AI summary) The RCEM expresses condolences and refers to existing guidance for re-attendance, paediatric emergency care standards, educational material on Group A Streptococcus, a Learning Disabilities toolkit, and the Oliver McGowan training programme. They state that questions about electronic patient records are best directed to NHS England. The RCPCH will share information and suggestions for local improvement from the coroner's report with its members via its patient safety portal and will discuss the report with the RCPCH Clinical Quality in Practice Committee to identify further actions. The Royal Free London Hospital has provided training on deteriorating conditions in children, including the use of the Paediatric Early Warning Score and sepsis identification tools, and has re-familiarised staff with the SBAR communication tool. A nurse champion has been appointed to lead training and audits and a pathway has been implemented to ensure reattendees are seen by the next available doctor.
Joanita Nalubowa
All Responded
2024-0453 13 Aug 2024
Ministry of Housing, Communities and Lo…
Suicide (from 2015)
Concerns summary (AI summary) Rigid Mental Health Act aftercare criteria lack flexibility, preventing suitable accommodation for patients whose historical residences are inappropriate, risking future harm by limiting discretion in placement decisions.
Action Planned (AI summary) The MHCLG will write to the local authorities concerned to remind them of their statutory duties, and the government will bring forward changes to social housing allocations regulations to apply exemptions to victims of domestic abuse from local authority residency and local connection tests.
Elizabeth Van Der Drift
All Responded
2024-0451 13 Aug 2024
Department of Health and Social Care Office for Product Safety and Standards Sainsburys +1 more
Product related deaths
Concerns summary (AI summary) Brightly coloured laundry pods and their sweet-like packaging are confused for food by people with dementia, and easy-to-open packaging increases the risk of accidental ingestion of toxic products.
Noted (AI summary) UKCPI expresses condolences and confirms that the laundry pouch packaging complies with GB CLP Regulation and industry PSP. They suggest that the packaging may have been left open or damaged. OPSS has spoken to the UKCPI, who are exploring a new awareness campaign for those with caring or safeguarding responsibilities, which OPSS will promote to local regulators. Sainsbury's states that their capsules already included a bittering agent and that the packaging adhered to A.I.S.E. guidelines. They have since changed their packaging to a cardboard box with a child-impeding closure, tested in line with AISE protocol. The HSE acknowledges the concerns regarding laundry tablet packaging and refers to existing regulations about the classification, labelling and packaging of hazardous substances, detailing specific requirements around outer and inner packaging.
Nimo Osman
All Responded
2024-0444 12 Aug 2024
East London NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A significant delay in calling an emergency ambulance after a patient's collapse was exacerbated by a senior nurse's continued belief that nurses cannot call 999 without a doctor's approval, undermining training efforts.
Action Taken (AI summary) ELFT has taken several actions, including conducting reflective practice sessions, disseminating key learning points to staff, and incorporating VTE risk screening into the nurses' observation form. They are updating their Physical Healthcare Policy to clarify VTE assessment procedures, expected November 2024.
Malika Hibu
All Responded
2024-0432 7 Aug 2024
Islington Borough Council Mayor of London Ministry of Housing, Communities and Lo… +1 more
Child Death (from 2015)
Concerns summary (AI summary) Peabody Housing Association failed to address an unsafe canal barrier, demonstrating a lack of boundary knowledge, neglected risk assessments, ignored resident complaints, and inaction on known safety hazards.
Action Planned (AI summary) Peabody has implemented emergency temporary fencing and developed proposals for permanent safety railings at the canal edge, while working with the London Borough of Islington and CRT/CIC for required approvals. They have also strengthened internal policies and procedures relating to resident safety and reporting concerns. Islington Council is working with Peabody on a planning application for safety fencing around the canal side area of the Crest Buildings development. Urban design lessons from this incident have been shared with Development Management Officers, and a planning application for another canal side residential development includes fencing. The Mayor of London will consider the concerns raised in the PFD report through his review of the London Plan, with public consultation planned for the second half of 2025 and adoption of the revised Plan in 2027. Any changes made to the NPPF by the government will also be considered. The government published an updated NPPF on 12 December 2024 that includes additional policy to consider the safety of children and other vulnerable users in proximity to open water, railways and other potential hazards.
Anna Elliot
All Responded
2024-0386 18 Jul 2024
East London Foundation Trust (ELFT)
Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)
Concerns summary (AI summary) The unit experienced widespread poor record-keeping, inadequate observation chart entries, and a rising trend of missed and falsified observations, indicating a failure to adhere to critical safety protocols despite training and previous PFD reports.
Action Taken (AI summary) ELFT has implemented measures including admin cover during team handovers to prevent missed calls, updated lone working policies, and revised observation policies with training. They are developing an e-obs platform with time-stamped entries and alerts for overdue observations.
Mahamoud Ali
All Responded
2024-0379 10 Jul 2024
East London NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Repeated instances of falsified observation records on mental health wards, despite previous interventions, indicate insufficient action to ensure patient safety and prevent future deaths.
Action Taken (AI summary) ELFT has taken steps to reduce the incidence of falsified observations, including improved data collection, analysis of falsified observations, and a review of the findings and improvements of the Human Factors Analysis work. They will also maintain involvement in the Cavendish Square community of practice and develop a learning system that includes learning from incidents and improvement work internally.
Brian Colby
All Responded
2024-0342 26 Jun 2024
HCA Healthcare UK
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A lack of clear protocols for escalating deteriorating patients and significant communication failures among clinicians led to delayed critical assessments. Misunderstandings regarding scan ordering and poor record-keeping also contributed.
Action Taken (AI summary) HCA Healthcare has implemented several actions, including reinforcing escalation protocols, updating observation and escalation policy, mandating training on patient deterioration, clarifying communication methods, and sharing learning from the case through internal safety alerts and HCA Quality Assurance programme.
Anoush Summers
All Responded
2024-0310 6 Jun 2024
London Borough Hackney Supreme Care Services Limited
Other related deaths
Concerns summary (AI summary) A reported broken wrist alarm was not repaired, carers failed to act or report the fault, lacked training on alarm testing, and there was no clear system for fault reporting between agencies.
Noted (AI summary) Supreme Care Services Ltd has reviewed all service users' pendants and undertakes weekly checks, reporting faults to the telecare provider and local authority. They also recommend clear flowcharts from the telecare provider and local authority on actions to take when equipment is faulty. TEC Quality describes the TEC Services Association's role as an independent industry expert and the Quality Standards Framework (QSF) used to audit service providers. They advocate for commissioners to specify the QSF in tenders but do not indicate specific actions taken or planned in response to the report.
Mohammed Akramuzzaman
All Responded
2024-0305 4 Jun 2024
British Transport Police
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Police failed to adequately assess a vulnerable individual, relying on minimal interaction and flawed assumptions about drug use. There was also a lack of follow-up checks and no demonstrable learning or procedural changes post-incident.
Action Planned (AI summary) The IOPC recommends that the British Transport Police (BTP) should explore opportunities to raise awareness of the Vulnerability Assessment Framework (VAF), outside of the Public Protection and Vulnerability training programme. British Transport Police (BTP) will be implementing a number of changes in response to the Prevention of Future Deaths report. These include piloting joint response vehicles (JRV) with mental health nurses, improving Section 136 and 297 detentions, delivering new mental health and wellbeing training and incorporating both clinical supervision and police staff with mental health expertise within HaRT.
Tracy McCarthy
All Responded
2024-0280 21 May 2024
Tredegar Practice
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Amitriptyline was prescribed above recommended doses for a contraindicated condition in a dependent patient, with overdose risk unflagged after hospitalisation, and risky monthly prescriptions issued due to inadequate record-keeping and over-reliance on individual doctor knowledge.
Action Planned (AI summary) The GP Partners plan to implement a Risk Management & Care Planning framework for complex patients, including identifying a lead GP, creating a central register, and conducting regular reviews. An update and report of the implementation will be provided towards the end of September 2024.
Jada Monoja
All Responded
2024-0269 17 May 2024
Department of Health and Social Care NHS England South London and Maudsley NHS
Suicide (from 2015)
Concerns summary (AI summary) An online risk assessment tool is not systematically updated or used per policy, resulting in incomplete and potentially misleading patient risk assessments, hindering effective management.
Noted (AI summary) NHS England highlights the Suicide Prevention Strategy and guidance to improve the culture of care for mental health inpatient services. Oxleas has designed a clinical risk training workshop, and participates in the Royal College of Psychiatrists’ Culture of Care Programme. The Department acknowledges concerns about the use of risk assessment tools and refers to NICE guidance and the 5-year Suicide Prevention Strategy for England. It highlights NHS England's work to improve risk management within mental health services, including guidance published in April 2024. The Trust will issue a blue light bulletin reminding clinical staff to update risk assessment documents, and will audit risk assessments using the 'Tendable' system. The Trust will also work with the National Culture of Care team to adapt the risk assessment and formulation tool.
Sean O’Connor
All Responded
2024-0257 8 May 2024
Canary Wharf Management Limited
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) The lack of mandatory checks for lone workers and failure to integrate safety discussions about required checks into routine worker briefings increased the risk of harm.
Action Planned (AI summary) Canary Wharf Management will trial a new feature for work authorisations involving lone working, including a mandatory prompt for welfare checks, to be conducted and recorded by CWML staff if requested. They will also update the Contractor Handbook and Lone Working Policy to apply to contractors.
Chanyang Li
All Responded
2024-0212 22 Apr 2024
Scape Living Student Accommodation
Suicide (from 2015)
Concerns summary (AI summary) Student accommodation windows lacked adequate restrictors, enabling a fatal fall from a sixth-story, highlighting a failure to address the known risk of students falling from windows.
Noted (AI summary) Scape Operations Ltd states that window restrictors were installed in 2018 per the National Code of Standards and are inspected quarterly, with any remedial works immediately undertaken, and therefore they propose no further action.