Inner North London
Coroner Area
Reports: 331
Earliest: Sep 2013
Latest: 11 Mar 2026
81% response rate (above 63% average).
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.
Emmanuel Ladapo
Historic (No Identified Response)
2024-0215
23 Apr 2024
Camden and Islington NHS Foundation Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Mental health services showed a lack of engagement with the patient's family and psychiatrists repeatedly failed to inquire about suicidal ideation during periods of clinical deterioration, despite prior similar omissions.
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.
Angela Carpos
All Responded
2024-0211
22 Apr 2024
MiHomecare
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Care home staff lacked adequate training and awareness to recognise aspiration pneumonia, and the company's training quality and policy knowledge were insufficient.
Action Planned
(AI summary)
MiHomecare is updating its training on choking/aspiration risks, to be released by the end of July, including a "Talking Head" discussion and updated prompt card via their new CCH Connect app. They are also reviewing care planning tools to specifically reference aspiration risks.
Alan Soane
All Responded
2024-0180
2 Apr 2024
Department of Health and Social Care
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A national shortage of Consultant Histopathologists resulted in an NHS Trust being unable to provide one for MDT meetings, leading to an incorrect cancer diagnosis. This poses a significant widespread risk to patients.
Noted
(AI summary)
NHS England references the Long-Term Workforce Plan and actions to increase domestic education, training, and recruitment, as well as improve culture and retention. The response also highlights the use of AI and investment in pathology and imaging networks to increase productivity. The Department acknowledges the concerns about Consultant Histopathologist shortages and refers to NHS England's response. It cites the NHS Long Term Workforce Plan's goals to increase medical school places and grow the NHS workforce, and notes the increasing number of histopathology consultants and trainees.
Rose Hollingworth
All Responded
2024-0150
Care Quality Commission
Home Dot Care Limited
Islington Social Services
Care Home Health related deaths
Concerns summary (AI summary)
The care agency failed to provide suitably trained and supervised carers, leading to errors in the care plan and inadequate monitoring of service performance for a vulnerable person.
Disputed
(AI summary)
HomeDot Care has implemented a sleeping protocol, enhanced staff training, fully transitioned to an electronic care recording system, and revised call management procedures. They also introduced a new daily communication system, mandated staff shadowing, updated policies, and committed to annual mock inspections. The CQC conducted a comprehensive inspection of HomeDotCare Limited, finding that the service had already implemented several risk mitigation actions, including individual fire risk assessments, a 'sleep protocol,' updated next-of-kin notification policies, and comprehensive staff training. First aid training was also arranged immediately after the inspection. Islington Council has submitted a 'Letter Before Claim for Judicial Review' challenging the coroner's decision to issue a PFD report against them, arguing procedural irregularity and seeking to have the report quashed against the Council. Islington Council describes its robust processes for monitoring care agency performance, including a dedicated contract management team and a recently updated provider audit approach to include resident and staff feedback. They also undertook a procurement exercise to reduce provider numbers to enhance quality and safety.
Vanessa Ford
Partially Responded
2024-0125
4 Mar 2024
London Borough of Camden
London Borough of Hackney
Network Rail
Railway related deaths
Concerns summary (AI summary)
Frequent public access to railway tracks is facilitated by low walls, ineffective safety measures, and street furniture, posing significant risks, including to vulnerable individuals and children.
Action Planned
(AI summary)
Hackney Council has removed recycling bins near Martel Place and is in discussions with highways and planning to improve identifying and flagging electrical apparatus and street furniture at such locations. Network Rail is working with the Local Authority to explore if further measures can be implemented to address the specific concerns identified by this incident. Works have already been scheduled to be undertaken on during early May to the access gate at Martel Place to increase the height and Vanguard anti-climb rollers may be installed.
Sandra Senior
All Responded
2024-0124
4 Mar 2024
Camden Council
Suicide (from 2015)
Concerns summary (AI summary)
Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively locked gate, allowed opportunistic access for suicide.
Action Taken
(AI summary)
The council removed the latch and hook from the communal door, installed an extra "Fire Brigade" lock on the rooftop exit, and relies on daily checks by the caretaking service to secure doors and report faults.
Kazarie Dwaah-Lyder
All Responded
2024-0072
9 Feb 2024
British Association of Paediatric Surge…
Royal college of Paediatrics and Child …
Royal College of Radiologists
Child Death (from 2015)
Concerns summary (AI summary)
A lack of national guidance exists for children with persistent symptoms of swallowed non-radio-opaque foreign objects, specifically regarding the need for endoscopy after negative initial imaging.
Action Planned
(AI summary)
The RCR confirms that a paediatric radiologist has been appointed to a multi-professional group led by BAPS, which will consider developing guidance on swallowing non-radio opaque objects. BAPS is leading a multi-professional working group to consider a generic pathway for all Foreign Body Ingestion (FBI) in children, with more specific guidance for commonly reported hazardous FBs and those that may be minimally or non radio opaque (radiolucent) on plain X-ray. The RCPCH will share information and suggestions for local improvement from the report with its paediatric members via its patient safety portal and for discussion with the RCPCH Clinical Quality in Practice group. They acknowledge the clinical working group set up by BAPS to look at guidance for button battery ingestion and suggest that the group consider the report.
Abdullah Popalzai
All Responded
2024-0066
5 Feb 2024
NHS England
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Acutely psychotic prisoners requiring transfer for treatment are left untreated and at risk due to a shortage of timely psychiatric hospital bed availability.
Action Planned
(AI summary)
NHS England is working to address issues with timely access to mental health beds for prisoners, focusing on increasing access to hospital beds pre-sentence, and is working to support local mental health systems to reduce pressure on inpatient services. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions.
REDACTED
All Responded
2024-0031
18 Jan 2024
London Fire Brigade
Suicide (from 2015)
Concerns summary (AI summary)
There was some delay in the attendance of LFB, and firefighters recognised that their ladders would not reach the roof of the flats and so called for an extended height ladder appliance; police were concerned that the extended height ladder appliance had not been requested from the outset.
Disputed
(AI summary)
The London Fire Brigade claims information from its personnel is incongruous with the coroner's report and requests further information to enable a proper response.
Nicholas Cork
All Responded
2024-0015
11 Jan 2024
Sapphire Independent Living
Community health care and emergency services related deaths
Concerns summary (AI summary)
Inadequate welfare check procedures, inconsistent recording, an unreliable IT system, and missed opportunities to assess a vulnerable resident led to a significant delay in discovering their condition.
Action Taken
(AI summary)
Sapphire has implemented several changes, including revisions to the 'At Risk' procedure, permanent night staff recruitment, shift pattern reviews to reduce burnout, and ongoing discussions with the London Borough of Camden regarding support needs for referrals.
Bernadette Faulkner
All Responded
2024-0008
4 Jan 2024
Energy UK
Ministry of Housing, Communities & Loca…
Other related deaths
Concerns summary (AI summary)
The electricity meter's excessive height and placement behind an inwardly opening door created a significant safety risk for access, compounded by the lack of industry standards for meter accessibility.
Noted
(AI summary)
Energy UK expresses condolences and notes that it does not represent all energy network companies. It outlines existing industry practices regarding meter placement, safety checks, and support for vulnerable customers, referencing Ofgem guidance. Ofgem introduced new rules in November 2023 restricting suppliers from involuntarily installing prepayment meters for specific vulnerable customers, and suppliers are now required to assess the safety of prepayment meters annually.
Bobby Lee
All Responded
2024-0007
4 Jan 2024
Product Safety and Standards
Other related deaths
Product related deaths
Concerns summary (AI summary)
A significant rise in fires from faulty e-bike/e-scooter lithium-ion batteries and unsuitable chargers, often from inferior conversion kits and unregulated online sales, highlights the lack of specific safety standards.
Action Planned
(AI summary)
The government is part of a taskforce to establish the root causes of e-bike fires. A British Standard is being developed for businesses to use within 12-18 months and the Warwick Manufacturing Group (WMG) expects to deliver their final report later this year. The government's response to the Product Safety Review is expected later this year.
Kimberley Liu
All Responded
2023-0544
21 Dec 2023
Department for Culture, Media and Sport
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Unregulated websites facilitate dangerous, unchecked sales of prescription-only sedative medications, actively instructing customers to evade detection, which exploits vulnerable individuals and poses a suicide risk.
Action Taken
(AI summary)
The MHRA addresses illegal sale of prescription medications, working with partners across government; the Online Safety Act will give powers to Ofcom to ensure platforms remove illegal content; a national near real time suspected suicide surveillance system was launched in November 2023.
Sarah Chappell
All Responded
2023-0523
7 Dec 2023
University College London Hospitals NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Multiple failures including delayed transfer, confusion over lead clinicians, inadequate pain relief, and critical mismanagement of a nasogastric tube led to a fatal aspiration. The hospital failed to conduct a proper investigation.
Action Taken
(AI summary)
UCLH has strengthened its governance structures, appointed a second learning disability nurse, instigated a process to review all deaths of patients with learning disabilities, convened a weekly incident review group, and actively promoted Learning Disability Awareness Week.
Luke Whitelaw
All Responded
2023-0486
27 Nov 2023
Oxleas NHS Foundation Trust
Suicide (from 2015)
Concerns summary (AI summary)
Missed opportunities for urgent psychiatric review and readmission occurred, alongside a lack of "professional curiosity," poor documentation, and inadequate risk assessment formulation in patient care.
Action Taken
(AI summary)
Oxleas NHS Foundation Trust updated its Acute Mental Health Patient Flow and Bed Management policy in December 2023, and introduced a single crisis assessment form on 22 January 2024. They also reinforced documentation standards and protected time for complex case discussions, with clinical leadership and psychology support.
Jennifer Whinney
All Responded
2023-0477
27 Nov 2023
Queens Hospital
Royal London Hospital
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical patient notes were not sent to an external appointment due to non-electronic records and a lack of clear responsibility for ensuring their transfer, risking incomplete medical history.
Action Taken
(AI summary)
Barts Health NHS Trust has undertaken several actions to reduce line infections at the Royal London Hospital, including providing education and training sessions for multidisciplinary surgical staff, and updating IPC statutory and mandatory training. They are also in the process of re-writing the ANTT policy with the microbiology and Infection Prevent and Control (IPC) teams. Barking Havering and Redbridge University Hospitals NHS Trust has revised its policy for sending patient notes to external hospital visits, with the updated policy approved on 22 January 2024. The revised policy includes explicit responsibilities, a checklist, and a signature section for acknowledging receipt of notes.
Mohammed Akram
All Responded
2023-0474
27 Nov 2023
Barnet Enfield and Haringey Mental Heal…
Suicide (from 2015)
Concerns summary (AI summary)
A lack of routine cross-referencing between prescribed and collected medication, and the failure to notify GPs when patients don't collect essential prescriptions, poses a significant risk.
Noted
(AI summary)
Barnet Enfield and Haringey Mental Health NHS Trust describes its usual procedures for when a client is not taking their medication as prescribed. They state that the expected standard is for the GP to be notified via email within 48 hours of the medical review when there are any changes to the client’s prescription or treatment plan.
Glenn Lockwood
All Responded
2023-0487
17 Nov 2023
Limehouse Practice
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Insufficient monitoring for Pregabalin abuse in a patient with a known drug abuse history was identified, and the review of record-keeping and prescribing issues for the drug was found to be inadequate.
Noted
(AI summary)
The response provides a summary of the inquest findings, including the deceased's medical history and the coroner's conclusion of a drug-related death. It notes that a report will be issued to the Limehouse Practice regarding medication prescribing and documentation practices. The Limehouse Practice will conduct SEA training for prescribers, review prescribing for patients at risk of dependence, document medication changes, and provide refresher training on EMIS prescribing function. They have contacted CGL/RESET for training and have improved internal communications.
Igor Szalapski
All Responded
2023-0445
13 Nov 2023
Depaul UK
Suicide (from 2015)
Concerns summary (AI summary)
Hostel staff failed to re-contact the crisis team despite a resident's deterioration, lacked meaningful engagement, and did not perform consistent welfare checks. Inadequate self-harm training and a chaotic culture contributed to missed opportunities for intervention.
Action Planned
(AI summary)
DePaul UK outlines steps to ensure staff recognise warning signs as a deterioration in mental health, make continued escalation and referrals, and ensure staff are well inducted, trained, managed and supported, will also ensure that individual case reviews continue alongside wider organisational reviews following serious incidents.
Claire Homer
All Responded
2023-0448
10 Nov 2023
Camden and Islington NHS Foundation Tru…
Other related deaths
Concerns summary (AI summary)
The absence of robust protocols for managing patient deterioration when key staff are on leave, or both contacts are absent, led to a critical email going unanswered, resulting in delayed care.
Action Taken
(AI summary)
Barnet, Enfield and Haringey Mental Health Trust discussed out-of-office responses and escalation procedures with staff, issued a template for out-of-office replies, ensured voicemail messages follow the same practice, updated online information with duty mobile numbers, reiterated the need for clear doctor cover arrangements, and emphasised the importance of balancing service needs with leave requests and clear patient handovers.
Frances Newbury
All Responded
2023-0443
10 Nov 2023
London Ambulance Service NHS Trust
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Paramedics failed to administer Naloxone despite a patient's reported illicit drug use and clear physical signs. This highlights a missed opportunity for potentially life-saving intervention in opiate overdose cases.
Noted
(AI summary)
The London Ambulance Service conducted a clinical review, stating that naloxone was not mandated in this instance. They highlight existing support for naloxone administration and offer to discuss ongoing work to improve cardiac arrest survival in London.